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.

DICKENSON COMMUNITY HOSPITAL 312 HOSPITAL DRIVE CLINTWOOD, VA 24228 Aug. 8, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
Based on clinical record review, facility document review, staff and other involved personnel interviews, the facility staff failed to ensure compliance with EMTALA requirements at 42 CFR ?489.24, Special responsibilities of Medicare hospitals in emergency cases. The failure of the provider to comply with this requirement resulted in an Immediate Jeopardy finding during the survey.

The findings include:

The facility staff failed to ensure an appropriate MSE (Medical Screening examination) and necessary stabilizing treatment were provided to Patient # 10, as well as failed to restrict the transfer of the patient until stabilized. Patient #10, after being discharged from the facility Emergency Department, was taken to another facility specializing in the care and treatment of patients with mental illness. Upon arrival to the mental health facility, Patient #10 was found to be acutely ill and in need of medical treatment. Patient #10 was transferred to an acute care hospital emergency department. The patient subsequently required transfer to a larger acute care hospital for further life sustaining treatment. Patient #10 was found to be in acute respiratory failure, sepsis, renal failure, liver failure, and required intubation and ventilator support.

Interviews, document reviews, and clinical record reviews resulted in the finding of Immediate Jeopardy.

Further detailed information is found within this report, specifically at:
42 CFR ?489.24 (a) (1) (i) (C-2406)
42 CFR ?489.24 (d) (1) (i) (C-2407)
42 CFR ?489.24 (e) (1) (2) (C-2409)
VIOLATION: MEDICAL SCREENING EXAM Tag No: C2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interview, facility document review, clinical record review, and other personnel interviews, the facility staff failed to ensure an appropriate medical examination (MSE) was provided for one (1) of 25 patients, Patient #10, who was brought to the emergency department (ED) for "medical clearance" prior to being transferred to a psychiatric facility.
Patient #10 was discharged from the ED and was taken to the local magistrate who issued a TDO (temporary detaining order) for a psychiatric facility. After arriving at the psychiatric facility, Patient #10 was determined not to be medically stable and was transferred to an acute care hospital ED and then transferred to another acute care hospital where the patient required treatment in the intensive care unit (ICU) on ventilator support.
Due to the providers' failure to comply with this requirement regarding ensuring a patient receives an appropriate MSE (Medical Screening Examination) and necessary stabilizing treatment, a finding of Immediate Jeopardy resulted.

Also, the facility staff failed to ensure the medical records of three (3) of 25 patients, (Patient #'s 2, 22, and 23) contained a physicians order for a psychiatric pre-screening/recommendation for further psychiatric treatment. The medical records of these patients also failed to have a copy of the pre-screening/recommendation or transfer form prior to transferring the patients to facilities equipped to care for patients with a psychiatric emergency.
The findings included:

1. Review of the clinical record revealed Patient #10 (MDS) dated [DATE], after being evaluated by the local CSB (Community Services Board), as it had been determined the patient required psychiatric treatment. Further review revealed orders for lab work and an EKG (electrocardiogram) ordered by the ED physician (Staff #3). A document "MSE/Medical Screening Exam" contained in the clinical record for Patient #10 was reviewed. This document evidenced the following: Vital signs: none documented. CHIEF COMPLAINT: (age), (gender) (circled) who presents with a chief complaint of: nothing was documented. REVIEW OF SYSTEMS: Constitutional - negative was circled. CV (Cardiovascular)- nothing was documented. Respiratory- Negative was circled. GI (Gastrointestinal)- negative was circled. GU (Gentourinary) -nothing was documented. Musculoskeletal- nothing was documented. Neuro (Neurological)- nothing was documented. PAST MEDICAL HISTORY: Nothing was documented. FOCUSED PHYSICAL EXAMINATION: Appearance- normal. Eyes- normal. ENT (ears, nose, throat)- normal. Respiratory- normal. Cardiovascular- normal. GI/GU- normal. Musculoskeletal- normal. Skin- normal. Neuro- normal. MEDICAL DECISION MAKING: Emergency Medical Condition: Yes/No- nothing was circled or documented. MEDICAL DIAGNOSIS: 1. Med. Clearance 2. Elevated LFT (liver function test) (arrow point upward meaning high or elevated) Creatinine. 3. Abnormal EKG<prob (probably) old. DISPOSITION: DISPOSITION DECISION TIME: nothing documented. Condition: Stable. Discharge to: nothing documented. Referral; nothing documented. Appointment: nothing documented. SIGNATURE: Disposition time: nothing documented. Disposition date: 7/18. The document contained the signature of Staff #3, MD.

An "MSHA (initials of corporate entity) Assessment Report" revealed an ED Triage assessment dated [DATE] at 15:23 (3:23 p.m.). This document evidenced, in part, the following: "Pain intensity- 3 ( pain scale 1 (lowest pain) to 10 (highest) pain rating). BP#1 - (Blood pressure- 90/58. Behavioral Health History- Bipolar. Triaged Chief complaint- Medical Clearance. Cardiac History- hypertension."

Lab studies were obtained on Patient #10 in the ED. The following is a summary listing of the lab studies (only significant abnormals are listed):
Test Result
Sodium 129
Chloride 94
BUN 85
Creatinine 3.00
BUN/Creatinine ratio 22
AST 704
ALT 513
Alkaline Phosphatase 233
Bilirubin, Total 3.5
Urine Benzo Screen positive
Urine Opiates screen positive
Urine Tricyclics Screen positive
WBC 12.6
Urinalysis- Urobilinogen 4.0
Urinalysis- Bilirubin Small

The EKG report dated 7/18/14 at 15:38 (3:38 p.m.) documented: Sinus Tachycardia - Possible left atrial abnormality - Prolonged QRS duration - Extensive Q waves - ST elevation + T wave inversion- POSSIBLE EXTENSIVE INFARCTION - AGE UNDETERMINED- Summary: Abnormal ECG- No previous ECG available for comparison.

A document "ED Discharge Disposition" dated 7/18/14 at 17:00 (5:00 p.m.) revealed: "discharged home: Yes. Patient's belongings given to: Patient. Pain scale at discharge: 0. ED Services other: exam. RX (prescription) given and S/S (signs/symptoms) of reaction reviewed: Yes. B/P: 100/56. Discharge time: 17:00. Discharge Condition from ED: Satisfactory. Brief description of services: EKG, Lab, X-ray, other. Discharge Instructions reviewed, pt (patient) verbalized understanding: Yes. Review of Press Ganey Survey with patient/resident: Yes." This Discharge Disposition was documented as being completed by Staff # 4.

Also contained in the clinical record was a document dated 7/21/14 at 07:45 (7:45 a.m.), "Clinical Notes Report" which evidenced: "Note: (sic) I made copies of the chart and got labs, mental health needed us to fax it to (name of city) to their doctors office. I put the copies in brown envelope and gave it to the police office (sic). I informed him to give it to (name) of mental health the paperwork to be faxed that we was busy working on a burn patient. When I completed the burn patient came out of the room (sic) room where the mental clearance patient was, was gone (sic) I assumed the patient had been discharged while I was in the room so I discharged him out of the computer. To my understanding a (sic) dr. (doctor) called back from (city) and jumped (name of ED physician). (Name of ED physician) was not aware of the patient being gone (sic) he had not discharged him either. I understand the miscommunication came when I gave the paperwork to the police officer to be faxed they thought they could leave with the patient. It was a (sic) mis communication. No fault of anyone." Entry was signed by Staff #4.

On 8/6/14 at 4:00 p.m., the surveyors interviewed Staff #3 (ED physician). Staff #3 stated: "(Patient #10) was brought in for medical clearance. No history was given to me, but some of the nurses knew him and that he/she had a psych history with abnormal behavior with alcohol and substance abuse in the past. When I came in and saw him/her, he/she said he/she wasn't sure why he/she was in the ER (emergency room ). I asked him/her if he/she had any problems and he/she said "none". He/she was alert, and talking. His/her B/P (blood pressure) was slightly low 90/40 or something like that, and because the B/P was low, I expressed some concern about that...he/she was otherwise asymptomatic, so I told the nurse to get an EKG, CBC, Comprehensive panel, and tox (toxicology) screen. The EKG showed non-specific changes and a conduction defect, but there was no previous EKG to compare it to. I expressed concern about the low blood pressure but the patient was with no complaints. They drew the labs and then we got busy seeing other patients. At some time, I looked at the labs and the Creatinine was high, the BUN was high, the LFTs were abnormal and the ALT, AST and I think the phosphorous was elevated. I think the billirubin may have been elevated, but I am not sure about that right now. I was struggling with what to do about that and I got busy seeing other patients as I was deciding what to do. The blood pressure was rechecked and it was improved and the next thing I saw on the board for Room 3, the patient had been in Room 3, was there was a new patient in that room. I asked what happened to the patient who was in Room 3, and was told the Sheriff took him/her away. I said the patient was not medically cleared. If a patient comes in for clearance the accepting facility calls us and we get the labs and send them. The LFT's were normal in 2012 and I had no EKG to compare. There were no other blood pressures to compare. I then got a call of concern from the accepting hospital. I told them the patient was not medically cleared. My plan was to consult with them or another physician or Nephrologist but I hadn't made up my mind. I talked with the Behavioral Health person. He/she said he/she had seen the patient and the patient was hallucinating at home and running around naked in his home. I don't think that was a cause to TDO (Temporary Detention Order) someone but I didn't get that history. There were no complaints of chest pain. The Sheriff took him away and then I got a call from (Name of accepting facility) with concerns. This was about 7:30 or 8:00, when (name of facility) called and (name of physician) wanted to know why I discharged the patient. The LFT and Creatinine was abnormal but I had a lab from 2012 that was normal. The (name) physician raised a concern of neurolepti[DIAGNOSES REDACTED] and wanted to know how the patient could be medically clear. I told him I did not clear the patient that I understood the patient had been taken by the Sheriff. We were both concerned. I called to find the patient and he/she was in the presence of the magistrate. I told them to bring him/her back but (name) of Behavioral Health said it was too late that they could not bring him/her back that he/she had already been TDO'd to (name of hospital) but that he/she (Behavioral Health assigned Staff # 5) would check with the magistrate but it was too late. I was told the Sheriff took the chart and where did I write medical clearance? I wrote in the diagnosis area, I never wrote medically cleared. I guess I need to clarify that. The nurse who accepted (name) and the Doctor called. I said, "Listen, I did not medically clear this patient". I was told by behavioral health that the patient had been TDO'd and they could not bring him/her back but that (receiving hospital) could send him/her back out for an evaluation...we were busy in the ER and the nurse gave the lab and the paperwork to the Sheriff and discharged him/her. There was a misunderstanding with Behavioral Health and the nurse thought the patient was discharged ... What I wrote on the chart was a diagnosis, not a disposition..."

On 8/6/14 at 9:50 a.m., Staff # 6 was interviewed (Medical Staff Quality). Staff #6 stated: "A physician's occurrence was entered and a peer review is scheduled for tomorrow (8/7/14). I did a summary of the occurrence and I brought it to the ED Medical Director for review and to decide whether a peer review would be done. I sent a letter to the physician involved and he/she had ten days to respond..." Staff #6 was interviewed as to whether the involved physician or other staff were interviewed. Staff #6 stated, "No. I did not interview the physician or the staff. I sent the letter to the physician and he/she responded with a letter...I do a summary of events. No nurses were interviewed..."

At 10:30 a.m., on 8/6/14 Staff # 7 (Risk Management) was interviewed. Staff #7 stated, "I became aware of the incident when I was attending a meeting at (name of hospital). The person from (hospital receiving facility for Patient #10) came up to me and because they knew I was Risk Management for the facility, asked me if I was aware of what had happened with this patient (Patient #10). He/she told me that the patient had been transferred to them and then immediately had to go to (name of hospital) and then to (name of hospital) and was put on a vent. As soon as I got back, I immediately reviewed the patient's medical record and saw that the patient had presented for a medical clearance and the labs were abnormal and the urine drug screen was also positive. I know there was a fear of seratoni[DIAGNOSES REDACTED] and that the issues could be medical rather than mental. I don't know that we knew that before he/she (Patient #10) went out the door. The doctor said they were busy and that the patient was ready to go pending labs. The chart was copied and laid on the desk and they gave report to the police but were not told to go. The police took the chart and left. I can't confirm or deny they tried to get him/her back but do know they were told a TDO had already been issued and they could not bring him/her (Patient #10) back...It was my understanding (Name of Staff # 3- ED physician) spoke with the magistrate...I did not talk to anyone as I didn't want to taint the information since it was going to peer review. We are trying to pull this all together so we can all get the patients the care they need without any falling through the cracks or doing something we should not do..."

On 8/6/14 at 10:45 a.m., the surveyor interviewed the Behavioral Health Worker (assigned Staff # 5 for the purposes of this report). Staff #5 stated: "I was the one who did the pre-screening for (Patient #10). There was a concern regarding this patients medical status from every facility I contacted. I cannot contact a facility for a bed or do a TDO until the patient is medically cleared. I received a brown paper envelope from the police officer with the patients labs, EKG, and medical clearance paperwork. There was a note from the ER attached to the front that said, "Please have mental health fax due to being busy". The deputy who brought the patient back said the patient could be transferred. At 8:11 p.m., the Doctor (ED physician) called and wanted the patient brought back. I said I had to check with the magistrate. At 8:13 p.m., I talked with the magistrate and he/she said there was no way to reverse the TDO once it had been issued as it was a court order. With each transfer, there has to be a doctor to doctor conference call. The psychiatrist from (name of hospital-name of psychiatrist) contacted (name of ER physician) and talked about the medical clearance. I do not know what time that occurred, but at 7:31 p.m., I spoke to (name of psychiatrist) and his exact words to me were "I do not feel this patient is medically cleared, however due to the new guidelines, we have to accept. We had a difference of opinion about this patient." He/She (psychiatrist) felt the patient was not medically cleared and (name of ED physician) felt he /she (Patient #10) was...it was after I spoke to (psychiatrist) that (ED physician) called to try to get the patient back..."

On 8/6/14 at 11:15 a.m., Staff #4 was interviewed. Staff #4 stated, "We were very busy. There were five patients in the ER and there are only two nurses and the one doctor. A burn patient came in who had second degree burns and left AMA during all this. This patient had head, neck and chest burns and his/her throat was black. I was begging this patient not to leave, so it was in the middle of all this when this happened with (Patient #10). We have no ward clerk, and the phone was ringing off the hook. I was in with the burn patient and I was dressed sterile to dress his/her wounds, but the phone kept ringing and ringing. I thought it may be the burn center, but it was mental health. They kept calling and calling wanting the labs and stuff faxed. I told them we were so busy that I couldn't do that right now. The police officer was even answering the phone for us. I told him (the police officer) that I would make the copies and give them to him to let mental health fax them because I had that burn patient. I told him (police) that he/she (Patient #10) had not been cleared and to tell (mental health) that I was working on this burn patient. I told him (police officer) that this is all he needed but the labs were out of whack and (name of physician) had not cleared him/her (Patient #10). I gave the envelope to (name of police officer). In the meantime I was having a problem with the burn patient trying to leave AMA... When I finally came out of the room he/she (Patient #10) was gone...at the end of the shift I was trying to make notes and I saw the chart laying there on my desk and I looked and saw the doctors signature and the diagnosis, and I didn't even ask. I took the last set of vitals I had got and I discharged him/her (Patient #10) out of the system because I thought he/she had been discharged . I took him/her out of the computer. The chart was where they normally are put when the doctor is finished with them and I saw the diagnosis and signature. (Name of physician Staff #3 ) called me at home and said I got him/her in trouble. He/She said "why did you discharge (Patient #10)?' I said "I didn't discharge him/her you did, your name and diagnosis was on the paper." I said "call them and get him/her (Patient #10) back!" He/She (Staff #3) said "Can I do that?" I told him/her to call them...I should have asked about the chart but it was sitting right there where my charts normally are if they have been discharged and I assumed it was discharged . If the signature or diagnosis had not been there I would have questioned it..." The surveyor inquired if the physician (Staff #3) had expressed a concern about Patient #10 to (Staff #4). Staff #4 stated "Not to me"...we were really busy. There is nothing we don't do here.."

At 1:45 p.m. on 8/6/14, Staff #7 was interviewed again regarding the facility's knowledge and response to the concern of the appropriate medical screening for Patient #10. Staff #7 stated, "I am still in the information gathering stages. In the meantime we put some stop-gap measures into place. The ED physicians are working with the Medical Director to develop a basic understanding of a medical clearance for TDO...we are working toward physician education and there are some emails for suggestions on how to proceed...further education of the staff is still needed. I didn't realize the patient had not been discharged because no nursing staff have been interviewed yet...I do not think staffing played a role in this, there were two nurses and one doctor on duty..."

On 8/6/14 at 2:30 p.m., the surveyor interviewed the Police Officer (Assigned Staff # 12 for the purposes of this report) who was in the ED with Patient #10 on 7/18/14. Staff #12 stated, "I was handed a folder with the patients information by the nurse. I asked "Is (he/she) ready to go?" The nurse said "Yep". I asked, "Does (he/she referring to Patient #10) need anything else?" The nurse said "Nope". I do not know the name of the nurse, but I would remember him/her if I saw him/her again...I know that (name of mental health worker) talked by phone to the doc (ED Physician) and he/she (ED physician) said the patient was not medically cleared, but I heard with my own ears the doc (ED physician) say to the nurse that the labs didn't look good but he'd (ED physician) just have to clear (him/her- Patient #10) and let the other hospital deal with it."

After review of the interviews and the clinical record for Patient #10, the survey team met at 8:45 a.m. on 8/7/14 and discussed the concern of Immediate Jeopardy regarding appropriate medical screening examinations under the EMTALA regulations. At 9:13 a.m. the Supervisor at the State Agency was contacted. With the Supervisor via telephone, Appendix Q was consulted and the team was in agreement with the concern for an Immediate Jeopardy issue. After consultation with the State Agency and notification to the Regional Office of CMS, the facility was notified by the survey team on 8/7/14 at 10:55 a.m., that an Immediate Jeopardy situation existed. The facility at that time was notified that an immediate plan of removal would be required.

At 4:45 p.m., on 8/7/14, the facility presented a plan of removal to the survey team. The plan of removal documented the following:

Strategy 1: Education
1.1 Identify opportunity for EMTALA & Behavioral Health Education to be completed by all ED providers.
1.2 Assignment of EMTALA Education for completion by all emergency room physicians from ECI.
1.3 Education to providers on appropriate selection of documentation tools.
1.4 ED physician to complete ECI education on medically clearing patients & EMTALA
1.5 ED providers and ED staff completion training on proper Temporary Detention Order (TDO) process.
1.6 EMTALA training for ED Nursing and ED Registration
1.7 ED Nursing to complete education pertaining to proper patient reassessment and documentation of reassessment.
Strategy 2: Policy
2.1 Development of a mental health patient management procedure for DCH (Hospital initials)
Strategy 3: Documentation
3.1 Immediately discontinue use of electronic Patient Rights and Responsibilities form.
3.2 Immediately begin using paper Patient Rights and responsibilities form that includes all needed fields to clearly define relationship of person signing form. Rights and responsibilities forms to be completed correctly to include accurate relationship status of person signing forms.
3.3 Development and deployment of a Pre-disposition checklist of all required elements for mental health.
3.4 Development and deployment of a clinical staffing plan to determine staffing levels to meet patient demand.
3.5 (Name of Behavioral Health) documentation required to be placed on all behavioral health patients charts prior to discharge.
3.6 Provider documentation of patients disposition/condition required on all charts prior to discharge.
3.7 All transfer forms competed appropriately.
Strategy 4: Performance Improvement
4.1 Daily all (Hospital initials ED) Mental Health patents charts reviewed for complete, appropriate and accurate documentation by Director of Patient Care Services and Medical Director.
4.2 70 (initials of ED) charts will be reviewed monthly for complete, accurate and appropriate documentation.
4.3 Development of monthly Behavioral health review Committee (names of members)
4.4 Monthly meeting with (behavioral health) to review results of chart reviews
4.5 Root Cause Analysis completed (Action Plan) by Friday August 15, 2014.

Completion dates for Immediate Removal: 8/7 and 8/8/14.

On 8/7/14 at 5:00 p.m., the facility was notified of the acceptance of the plan of removal.


2. On 8/7/14 the medical records of Patient #22 and 23 were reviewed from approximately 9 A.M to 11 A.M.

Patient #22 was seen on 7/28/14 with the initial diagnosis of [DIAGNOSES REDACTED]
The physician's assessment Page 1: Chief Complaint documented by the physician is "Suicidal Thoughts" . The physician indicated the Timing of the thoughts was "constant" , that Patient #22's Character was "Depressed" .
The physician indicated Patient #22 was positive for the following under each heading: Review of Systems Psych: Neg; Past Medical History: Schizophrenia.
Page 2: Physical Examination: Psychiatric: Normal; Differential Diagnoses: Suicidal Ideation with a note stating, "Pt (Patient) discharged to behavioral health Pt. accepted (Name of Hospital Psychiatric Treatment Center)" ; ED Physician Diagnoses 1. Depression/Suicidal Ideations 2. "Leukocytosis ? (There was nothing beside of the question mark) Non-specific" ; Phys. Notification/Consults: "Pt. being (there was nothing written after the word being)" ; Disposition: "Home, Stable" .
The Clinical Notes written by a registered nurse stated, "(Name of Behavioral Health Person) with Behavioral Health has been here and advises the Pt. is going voluntarily to (Name of psychiatric treatment center) to be admitted there. (He/She) is being discharged to (His/Her) family."
The medical record did not contain a copy of the psychiatric pre-screenings/recommendation and did not have a completed transfer form indicating another facility had been contacted regarding the need to transfer Patient #22 or that Patient #22 was in agreement with the transfer, prior to transferring the patient to a facility equipped to care for patients with a psychiatric emergency.
Patient #23 was seen on 7/31/14 for an initial diagnosis of [DIAGNOSES REDACTED]
The physician's assessment Page 1: Chief Complaint documented by the physician is "Hx per Behavioral Health. Anxiety, very upset. Had pulled a shotgun on her/his husband/wife and had a handful of pills. Possibly panic attack. Hx of Bad Nerves" . The physician indicated the Character of Patient #23 was "Depressed, Anxious" .
The physician indicated Patient #23 was positive for the following under each heading: Review of Systems Psych: "Anxious, Depressed" ; Past Medical History: "Anxiety Depression"
Page 2: Physical Examination: Psychiatric: Anxious Depressed; Mental Status Exam: Mood: "depressed, angry, agitated, anxious" ; Appearance: "Clean" ; Thought Process: "Illogical" ; Insight: "Poor" ; Memory: "Intact" ; Judgment: "Impaired, Danger to others" : "Yes; Patient Medically stable for Transfer" ; Differential Diagnoses: Is left blank; ED Physician Diagnoses 1. Acute Psychotic Episode; Phys. Notification/Consults: is blank; Disposition: Condition: "Stable" Transferred to " Custody of (Initials of County CSB) to TDO (Temporary Detention Order)" .
The Clinical Notes written by a registered nurse state, "(Name of Behavioral Health Person) with Behavioral Health arrived with pt. along with family members."
The medical record did not contain a copy of the psychiatric pre-screenings/recommendation and did not have a completed transfer form indicating another facility had been contacted regarding the need to transfer Patient #23 or that Patient #23 was in agreement with the transfer, prior to transferring the patient to a facility equipped to care for patients with a psychiatric emergency.
Staff Member #2 was asked to review the medical records with the surveyor of several other patients (Patients #1 and #4) who initially did not have a psych evaluation/pre-screening form on their medical record on 8/6/14. Staff Member #2 stated, "I understand why that is needed now but they (CSB) don't usually leave a copy of their screening."
Between the hours of 8:00 a.m. and 2:00 p.m. on 8/6/2014, Patient # 2's record was reviewed. Patient # 2 was brought to the emergency Department (ED), on 5/5/14, by law enforcement for a medical clearance, with an initial diagnosis of [DIAGNOSES REDACTED]

The physician's assessment Page 1: Chief Complaint documented by the physician that "pt (patient) not being completely responsive verbally, though he/she is following some commands". Character was "Depressed". Related history documented "Patient seems to be catatonic". Under review of systems Psych is documented as "Depressed".

Page 2: Physical Examination: Psychiatric: Normal. Mental Status Exam: all findings were bracketed with "Pt won't answer?" except that Mood: was marked as "Depressed". Patient Medically Stable for: left blank; Differential Diagnosis: [DIAGNOSES REDACTED]

MSHA Assessment Report Page 1 of 1 date 5/5/2014, time 17:13 (5:13 p.m.), the nurse documented the following: ED Discharge Disposition: discharged Location from ED: "DCSD", Discharge condition from ED: "Satisfactory", Discharge instructions reviewed, pt. verbalized understanding: "Yes", discharged to other Facility (ED): "Yes". The record did not document to what facility Patient # 2 was discharged .

The Acknowledgement and Receipt of Discharge Instructions on Patient # 2's record dated 5/5/2014 at 17:12 appeared to have Patient # 2's name along with another signature. When interviewed between 8:00 AM and 2:00 PM on 8/6/2014, Staff Person # 2 was unable to determine who signed the form.

Findings of the survey were discussed with the facility Administrator, Director of Patient Care, Quality and Risk Management, the Chief Executive Officer, and the Chief Nursing Officer on 8/7/14.

The survey team reviewed the ' Emergency Medical Treatment and Patient Transfer ' Policy and Procedure (P&P). The policy had a creation date of 7/1/99 with the most recent review and effective date of 11/1/13.
The P&P addressed a Medical Screening Exam (MSE) and Emergency Medical Condition (EMC), in part, as follows:
" An examination performed by a Qualified Medical Personnel (QMP) to reach with reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition (EMC) does or does not exist. The MSE must be performed in a non-discriminatory manner. Triage does not constitute an MSE. "
Emergency Medical Condition: " A medical condition manifesting itself by acute symptoms of [DIAGNOSES REDACTED]
1. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
2. Serious impairment of bodily function; or
3. Serious dysfunction of nay bodily organ or part
4. (relates to pregnancy)
5. With respect to an individual suspected of a psychiatric emergency;
a. That the individual has threatened or attempted suicide or to inflict serious bodily harm on himself/herself;
b. That the individual has threatened or attempted homicide or other violent behavior; or
c. That the individual has placed others in reasonable fear of violent behavior and serious physician (sic) harm to them; or
d. That the individual is unable to avoid severe impairment or injury from specific risks.
Qualified Medical Personnel (QMP): Physicians duly appointed to the hospital Medical Staff holding adequate privilages to perform an MSE; Advanced Practice Registered Nurses or Physician Assistants duly appointed to the hospital Allied Health Professional Staff holding adequate privileges to perform an MSW; resident physicians; and for obstetric medical screening exams, Registered Nurses employed by the hospital who have demonstrated competencies to perform MSEs.
Policy: The MSE must be used to determine whether an emergency medical condition exists or whether a woman is in true labor, and must be provided regardless of a patient ' s ability to pay, source of payment, race, diagnosis, color, national origin or disability. The MSE may not be delayed to inquire about insurance or payment status.
Procedure: Any person who comes to a dedicated emergency department seeking examination or treatment for any medical condition must be provided an MSE by the hospital ' s QMP to determine if an EMC exists or is a woman is in labor.
Triage does not constitute an MSE.
If it is determined that an EMC exists or the woman is in true labor, the QMP shall do everything within the capabilities of the facility and staff to stabilize the patient...
VIOLATION: STABILIZING TREATMENT Tag No: C2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interview, facility document review, clinical record review, and review of documents from receiving hospitals, the facility staff failed to ensure stabilizing treatment was provided for Patient #10 who had an emergency medical condition prior to discharge.

Patient #10 presented to the emergency room for "medical clearance" for mental health concerns. The patient was determined to have abnormal labs and an EKG but was discharged without treatment or further investigation. The patient was transferred to a mental health facility and due to the severity of the condition the mental health facility transferred the patient to another acute care hospital emergency room , who in turn transferred the patient to a larger acute care hospital for intensive care and ventilator support.

Due to the providers' failure to comply with this requirement regarding ensuring a patient receives necessary stabilizing treatment, a finding of Immediate Jeopardy resulted.

The findings included:

Review of the clinical record revealed Patient #10 presented to the ED (Emergency Department) on 7/18/14 after being evaluated by the local CSB (Community Services Board) for a medical clearance, as it had been determined the patient required psychiatric treatment. Further review revealed orders for lab work and an EKG (electrocardiogram) ordered by the ED physician (Staff #3). A document "MSE/Medical Screening Exam" contained in the clinical record for Patient #10 was reviewed. This document evidenced the following: Vital signs: none documented. CHIEF COMPLAINT: [AGE] year old (gender) (circled) who presents with a chief complaint of: nothing was documented. REVIEW OF SYSTEMS: Constitutional - negative was circled. CV (Cardiovascular)- nothing was documented. Respiratory- Negative was circled. GI (Gastrointestinal)- negative was circled. GU (Gentourinary) -nothing was documented. Musculoskeletal- nothing was documented. Neuro (Neurological)- nothing was documented. PAST MEDICAL HISTORY: Nothing was documented. FOCUSED PHYSICAL EXAMINATION: Appearance- normal. Eyes- normal. ENT (ears, nose, throat)- normal. Respiratory- normal. Cardiovascular- normal. GI/GU- normal. Musculoskeletal- normal. Skin- normal. Neuro- normal. MEDICAL DECISION MAKING: Emergency Medical Condition: Yes/No- nothing was circled or documented. MEDICAL DIAGNOSIS: 1. Med. Clearance 2. Elevated LFT (liver function test) (arrow point upward meaning high or elevated) Creatinine. 3. Abnormal EKG<prob (probably) old. DISPOSITION: DISPOSITION DECISION TIME: nothing documented. Condition: Stable. Discharge to: nothing documented. Referral; nothing documented. Appointment: nothing documented. SIGNATURE: Disposition time: nothing documented. Disposition date: 7/18. The document contained the signature of Staff #3, MD.

An "MSHA (initials of corporate entity) Assessment Report" revealed an ED Triage assessment dated [DATE] at 15:23 (3:23 p.m.). This document evidenced, in part, the following: "Pain intensity- 3 ( pain scale 1 (lowest pain) to 10 (highest) pain rating). BP#1 - (Blood pressure- 90/58. Behavioral Health History- Bipolar. Triaged Chief complaint- Medical Clearance. Cardiac History- hypertension."

Lab studies were obtained on Patient #10 in the ED. The following is a summary listing of the lab studies (only significant abnormal's are listed):
Test Result
Sodium 129
Chloride 94
BUN 85
Creatinine 3.00
BUN/Creatinine ratio 22
AST 704
ALT 513
Alkaline Phosphatase 233
Bilirubin, Total 3.5
Urine Benzo Screen positive
Urine Opiates screen positive
Urine Tricyclics Screen positive
WBC 12.6
Urinalysis- Urobilinogen 4.0
Urinalysis- Bilirubin Small

The EKG report dated 7/18/14 at 15:38 (3:38 p.m.) documented: Sinus Tachycardia - Possible left atrial abnormality - Prolonged QRS duration - Extensive Q waves - ST elevation + T wave inversion- POSSIBLE EXTENSIVE INFARCTION - AGE UNDETERMINED- Summary: Abnormal ECG- No previous ECG available for comparison.

A document "ED Discharge Disposition" dated 7/18/14 at 17:00 (5:00 p.m.) revealed: "discharged home: Yes. Patient's belongings given to: Patient. Pain scale at discharge: 0. ED Services other: exam. RX (prescription) given and S/S (signs/symptoms) of reaction reviewed: Yes. B/P: 100/56. Discharge time: 17:00. Discharge Condition from ED: Satisfactory. Brief description of services: EKG, Lab, X-ray, other. Discharge Instructions reviewed, pt (patient) verbalized understanding: Yes. Review of Press Ganey Survey with patient/resident: Yes." This Discharge Disposition was documented as being completed by Staff # 4.

Also contained in the clinical record was a document dated 7/21/14 at 07:45 (7:45 a.m.), "Clinical Notes Report" which evidenced: "Note: (sic) I made copies of the chart and got labs, mental health needed us to fax it to (name of city) to their doctors office. I put the copies in brown envelope and gave it to the police office (sic). I informed him to give it to (name) of mental health the paperwork to be faxed that we was busy working on a burn patient. When I completed the burn patient came out of the room (sic) room where the mental clearance patient was, was gone (sic) I assumed the patient had been discharged while I was in the room so I discharged him out of the computer. To my understanding a (sic) dr. (doctor) called back from (city) and jumped (name of ED physician). (Name of ED physician) was not aware of the patient being gone (sic) he had not discharged him either. I understand the miscommunication came when I gave the paperwork to the police officer to be faxed they thought they could leave with the patient. It was a (sic) mis communication. No fault of anyone." Entry was signed by Staff #4.

Clinical records for Patient #10 were obtained from the mental health facility where the patient first arrived after being discharged from the facility emergency department. This clinical record evidenced the following:

"Short Stay Discharge Summary- admitted [DATE]
Chief Complaint: (name of Patient #10) was a (age) (gender) sent to (name of mental health hospital) for his/her first admission here on a TDO (temporary detention order) obtained after a medical screening at (name of originating hospital)...History of present Illness: According to prescreening documents (name of patient spouse) noticed changes in his/her behavior shortly after his/her Elavil was increased...visual hallucinations...secluding...picking at imaginary things...crawling around on the floor...long history of mood swings marked by depression...During the interview at (this hospital) (name of Patient #10) was unable to give coherent responses to questions, therefore history was very limited coming mostly from the records received from (originating hospital).. Hospital Course: Friday evening (Name of Patient #10) was prescreened at an area jail and seen at (name of hospital ER) for medical clearance by (Name of physician Staff #3). After discussion with the (initials of mental health hospital) on duty physician, (Name of Staff #3) decided that (Patient #10) was not medically stable and attempted to forestall the transfer of (Patient #10). A TDO was issued however and the Magistrate stated there was no legal mechanism to retract it. The police transported (Patient #10) to (initials of mental health hospital). The on duty told (Staff #3) during the first of two telephone conversations that he did not believe this individual was medically stable but that (initials of mental health hospital) could not refuse (Patient #10) due to Virginia law. On arrival (Patient #10) mental status was most consistent with delirium. The clinical diagnosis was supported by laboratories indicating:
a) acute renal failure (Creatinine 3.0, BUN 85)
b) liver failure (Bili 3.5, AST 704, ALT 513)
c) cardiac conduction abnormalities (Q waves, ST elevation, T wave inversion) were noted on EKG
d) Urine drug screen was positive for opiates, benzodiazepines, and tricyclics.

Physical exam was significant for mental status confusion, a questionable infected laceration on the left buttocks, tachycardia, and hypotension.

(Name of Physician) rapidly assessed the patient and referred him/her for evaluation at (name of local hospital). He/She was then admitted to (name of larger acute care hospital) and thus never seen by this author or members of the C team. His/Her TDO was held over until clinical findings at (initials of larger acute care hospital) confirmed that he/she was indeed very medically ill..."

The clinical record from the larger acute care hospital was obtained for Patient #10. This record evidenced a"Consultation Report" dated 7/19/14 which revealed, "History of Present Illness: ...transferred to (name of hospital) from (name of second ED) for evaluation and treatment of apparent respiratory failure. By history the patient had a change in his/her mental status with increasing confusion and psychosis for several days prior to his/her admission. He/She been evaluated at the (name of ED patient first presented to) on 7/18/14 for apparent TDO order. The (name of mental hospital) subsequently returned the patient to (the second ED) where he/she was evaluated. The patient (sic) and acute renal failure, elevation of his/her liver function tests, and was confused and agitated...at the time of his/her admission, the patient was felt to have components of possible sepsis with hepatic failure, renal failure and metabolic [DIAGNOSES REDACTED]...he/she was intubated because of progressive respiratory dysfunction..."

"Discharge Diagnoses" documented on 7/29/14 were as follows:
1. Acute respiratory failure
2. Altered mental status
3. Severe [DIAGNOSES REDACTED] with ejection fraction of 20%
4. History of Alcohol abuse
5. End stage liver disease with septic cirrhosis
6. Severe sepsis
7. Acute episodes of hypotension
8. Acute renal failure
9. Hyponatremia
10. Troponinemia
11. Hypertension
12. Metabolic [DIAGNOSES REDACTED]
13. COPD (Chronic obstructive pulmonary disease)
14. Diabetes

On 8/6/14 at 4:00 p.m., the surveyor interviewed Staff #3 (ED physician). Staff #3 stated: "(Patient #10) was brought in for medical clearance. No history was given to me, but some of the nurses knew him and that he/she had a psych history with abnormal behavior with alcohol and substance abuse in the past. When I came in and saw him/her, he/she said he/she wasn't sure why he/she was in the ER (emergency room ). I asked him/her if he/she had any problems and he/she said "none". He/she was alert, and talking. His/her B/P (blood pressure) was slightly low 90/40 or something like that, and because the B/P was low, I expressed some concern about that...he/she was otherwise asymptomatic, so I told the nurse to get an EKG, CBC, Comprehensive panel, and tox (toxicology) screen. The EKG showed non-specific changes and a conduction defect, but there was no previous EKG to compare it to. I expressed concern about the low blood pressure but the patient was with no complaints. They drew the labs and then we got busy seeing other patients. At some time, I looked at the labs and the Creatinine was high, the BUN was high, the LFTs were abnormal and the ALT, AST and I think the phosphorous was elevated. I think the billirubin may have been elevated, but I am not sure about that right now. I was struggling with what to do about that and I got busy seeing other patients as I was deciding what to do. The blood pressure was rechecked and it was improved and the next thing I saw on the board for Room 3, the patient had been in Room 3, was there was a new patient in that room. I asked what happened to the patient who was in Room 3, and was told the Sheriff took him/her away. I said the patient was not medically cleared. If a patient comes in for clearance the accepting facility calls us and we get the labs and send them. The LFT's were normal in 2012 and I had no EKG to compare. There were no other blood pressures to compare. I then got a call of concern from the accepting hospital. I told them the patient was not medically cleared. My plan was to consult with them or another physician or Nephrologist but I hadn't made up my mind. I talked with the Behavioral Health person. He/she said he/she had saw the patient and the patient was hallucinating at home and running around naked in his home. I don't think that was a cause to TDO someone but I didn't get that history. There were no complaints of chest pain. The Sheriff took him away and then I got a call from (name of accepting facility) with concerns. This was about 730 or 8:00, when (name of facility) called and (name of physician) wanted to know how come I discharged the patient. The LFT and Creatinine was abnormal but I had a lab from 2012 that was normal. The (name) physician raised a concern of neurolepti[DIAGNOSES REDACTED] and wanted to know how the patient could be medically clear. I told him I did not clear the patient that I understood the patient had been taken by the Sheriff. We were both concerned. I called to find the patient and he/she was in the presence of the magistrate. I told them to bring him/her back but (name) of Behavioral Health said it was too late that they could not bring him/her back that he/she had already been TDO'd to (name of hospital) but that he/she (Behavioral Health assigned Staff # 5) would check with the magistrate but it was too late. I was told the Sheriff took the chart and where did I write medical clearance? I wrote in the diagnosis area, I never wrote medically cleared. I guess I need to clarify that. The nurse who accepted (name) and the Doctor called. I said "Listen, I did not medically clear this patient". I was told by behavioral health that the patient had been TDO'd and they could not bring him/her back but that (receiving hospital) could send him/her back out for an evaluation...we were busy in the ER and the nurse gave the lab and the paperwork to the Sheriff and discharged him/her. There was a misunderstanding with Behavioral Health and the nurse thought the patient was discharged ... What I wrote on the chart was a diagnosis, not a disposition..."

After review of the interviews and the clinical record for Patient #10, the survey team met at 8:45 a.m. on 8/7/14 and discussed the concern of Immediate Jeopardy regarding appropriate medical screening examinations under the EMTALA regulations. At 9:13 a.m. the Supervisor at the State Agency was contacted. With the Supervisor via telephone, Appendix Q was consulted and the team was in agreement with the concern for an Immediate Jeopardy issue. After consultation with the State Agency and notification to the Regional Office of CMS, the facility was notified by the survey team on 8/7/14 at 10:55 a.m., that an Immediate Jeopardy situation existed. The facility at that time was notified that an immediate plan of removal would be required.

At 4:45 p.m., on 8/7/14, the facility presented a plan of removal to the survey team. The plan of removal documented the following:

Strategy 1: Education
1.1 Identify opportunity for EMTALA & Behavioral Health Education to be completed by all ED providers.
1.2 Assignment of EMTALA Education for completion by all emergency room physicians from ECI.
1.3 Education to providers on appropriate selection of documentation tools.
1.4 ED physician to complete ECI education on medically clearing patients & EMTALA
1.5 ED providers and ED staff completion training on proper Temporary Detention Order (TDO) process.
1.6 EMTALA training for ED Nursing and ED Registration
1.7 ED Nursing to complete education pertaining to proper patient reassessment and documentation of reassessment.
Strategy 2: Policy
2.1 Development of a mental health patient management procedure for DCH (Hospital initials)
Strategy 3: Documentation
3.1 Immediately discontinue use of electronic Patient Rights and Responsibilities form.
3.2 Immediately begin using paper Patient Rights and responsibilities form that includes all needed fields to clearly define relationship of person signing form. Rights and responsibilities forms to be completed correctly to include accurate relationship status of person signing forms.
3.3 Development and deployment of a Pre-disposition checklist of all required elements for mental health.
3.4 Development and deployment of a clinical staffing plan to determine staffing levels to meet patient demand.
3.5 (Name of Behavioral Health) documentation required to be placed on all behavioral health patients charts prior to discharge.
3.6 Provider documentation of patients disposition/condition required on all charts prior to discharge.
3.7 All transfer forms competed appropriately.
Strategy 4: Performance Improvement
4.1 Daily all (Hospital initials ED) Mental Health patents charts reviewed for complete, appropriate and accurate documentation by Director of Patient Care Services and Medical Director.
4.2 70 (initials of ED) charts will be reviewed monthly for complete, accurate and appropriate documentation.
4.3 Development of monthly Behavioral health review Committee (names of members)
4.4 Monthly meeting with (behavioral health) to review results of chart reviews
4.5 Root Cause Analysis completed (Action Plan) by Friday August 15, 2014.

Completion dates for Immediate Removal: 8/7 and 8/8/14.

On 8/7/14 at 5:00 p.m., the facility was notified of the acceptance of the plan of removal.

The survey team reviewed the ' Emergency Medical Treatment and Patient Transfer ' Policy and Procedure (P&P). The policy had a creation date of 7/1/99 with the most recent review and effective date of 11/1/13.
The policy and procedure defined Stabilization as: " To provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from, or occur during the transfer of the individual from a facility, or that the woman has delivered the child and the placenta. A patient will be deemed stabilized if the treating physician attending to the patient in the Emergency Department/hospital has determined, within reasonable clinical confidence, that the emergency medical condition has been resolved, the determination of whether they are stable " medically " may occur in one of the following two circumstances:
1. For the purpose of transferring a patient from one facility to a second facility " stable for transfer " and
2. For the purpose of discharging a patient other than for the purpose of transfer form one facility to another facility " stable for discharge " "
Policy: For all patients, each hospital must utilize all resources that are available within its staff and facility to provide the MSE and treatment necessary to stabilize an EMC or provide treatment for labor.
Procedure: A patient with an EMC who has not been stabilized ...may not be transferred to another facility unless:
a. The patient or legal representative requests a transfer.
b. The hospital does not have the capability or physical capacity to treat the patient and the physician determines and certifies in a signed writing that based on the assessed needs of the patient at the time of the transfer, the medical benefits reasonably expected from medical treatment at another facility outweigh the increased risks to the patient.
VIOLATION: APPROPRIATE TRANSFER Tag No: C2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interviews, clinical record review, and facility document review, the facility staff failed to ensure 1(one) of 25 (twenty-five) patients, Patient #10, who had an emergency medical condition (EMC) was not transferred until the four requirements of an appropriate transfer were met. 1. The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual's health 2. The receiving facility has agreed to accept the patient, has space and qualified personnel available for the treatment. 3. The transferring hospital sends to the receiving facility all medical records related to the emergency medical condition which are available at the time of transfer and; 4. the transfer is effected through qualified personnel and transportation equipment.

Patient #10 had an EMC which was not treated or stabilized. The patient was discharged to a facility which was not appropriate for the care needed.

Due to the providers' failure to comply with this requirement regarding ensuring a patient receives necessary stabilizing treatment prior to transfer, a finding of Immediate Jeopardy resulted.

Also, the facility staff failed to ensure 11 of 25 patients (Patients #1, 2, 8, 11, 14, 17, 21, 22, 23, and 25) medical records contained a transfer Authorization Form and one of 25 (Patient #4) had a Transfer Authorization that was incomplete.
The findings included:

1. Review of the clinical record revealed Patient #10 (MDS) dated [DATE] after being evaluated by the local CSB (community services board) for a medical clearance, as it had been determined the patient required psychiatric treatment. Further review revealed orders for lab work and an EKG (electrocardiogram) ordered by the ED physician (Staff #3). A document "MSE/Medical Screening Exam" contained in the clinical record for Patient #10 was reviewed. This document evidenced the following: Vital signs: none documented. CHIEF COMPLAINT: [AGE] year old (gender) (circled) who presents with a chief complaint of: nothing was documented. REVIEW OF SYSTEMS: Constitutional - negative was circled. CV (Cardiovascular)- nothing was documented. Respiratory- Negative was circled. GI (Gastrointestinal)- negative was circled. GU (Gentourinary) -nothing was documented. Musculoskeletal- nothing was documented. Neuro (Neurological)- nothing was documented. PAST MEDICAL HISTORY: Nothing was documented. FOCUSED PHYSICAL EXAMINATION: Appearance- normal. Eyes- normal. ENT (ears, nose, throat)- normal. Respiratory- normal. Cardiovascular- normal. GI/GU- normal. Musculoskeletal- normal. Skin- normal. Neuro- normal. MEDICAL DECISION MAKING: Emergency Medical Condition: Yes/No- nothing was circled or documented. MEDICAL DIAGNOSIS: 1. Med. Clearance 2. Elevated LFT (liver function test) (arrow point upward meaning high or elevated) Creatinine. 3. Abnormal EKG<prob (probably) old. DISPOSITION: DISPOSITION DECISION TIME: nothing documented. Condition: Stable. Discharge to: nothing documented. Referral; nothing documented. Appointment: nothing documented. SIGNATURE: Disposition time: nothing documented. Disposition date: 7/18. Document contained the signature of Staff #3, MD.

An "MSHA (initials of corporate entity) Assessment Report" revealed an ED Triage assessment dated [DATE] at 15:23 (3:23 p.m.). This document evidenced, in part, the following: "Pain intensity- 3 ( pain scale 1 (lowest pain) to 10 (highest) pain rating). BP#1 - (Blood pressure- 90/58. Behavioral Health History- Bipolar. Triaged Chief complaint- Medical Clearance. Cardiac History- hypertension."

Lab studies were obtained on Patient #10 in the ED. The following is a summary listing of the lab studies (only significant abnormal's are listed):
Test Result
Sodium 129
Chloride 94
BUN 85
Creatinine 3.00
BUN/Creatinine ratio 22
AST 704
ALT 513
Alkaline Phosphatase 233
Bilirubin, Total 3.5
Urine Benzo Screen positive
Urine Opiates screen positive
Urine Tricyclics Screen positive
WBC 12.6
Urinalysis- Urobilinogen 4.0
Urinalysis- Bilirubin Small

The EKG report dated 7/18/14 at 15:38 documented: Sinus Tachycardia - Possible left atrial abnormality - Prolonged QRS duration - Extensive Q waves - ST elevation + T wave inversion- POSSIBLE EXTENSIVE INFARCTION - AGE UNDETERMINED- Summary: Abnormal ECG- No previous ECG available for comparison.

A document "ED Discharge Disposition" dated 7/18/14 at 17:00 (5:00 p.m.) revealed: "discharged home: Yes. Patient's belongings given to: Patient. Pain scale at discharge: 0. ED Services other: exam. RX (prescription) given and S/S (signs/symptoms) of reaction reviewed: Yes. B/P: 100/56. Discharge time: 17:00. Discharge Condition from ED: Satisfactory. Brief description of services: EKG, Lab, X-ray, other. Discharge Instructions reviewed, pt (patient) verbalized understanding: Yes. Review of Press Ganey Survey with patient/resident: Yes." This Discharge Disposition was documented as being completed by Staff # 4.

Clinical records for Patient #10 were obtained from the mental health facility where the patient first arrived after being discharged from the facility emergency room . This clinical record evidenced the following:
"Short Stay Discharge Summary- admitted [DATE]
Chief Complaint: (name of Patient #10) was a (age) (gender) sent to (name of mental health hospital) for his/her first admission here on a TDO (temporary detention order) obtained after a medical screening at (name of originating hospital)...History of present Illness: According to prescreening documents (name of patient spouse) noticed changes in his/her behavior shortly after his/her Elavil was increased...visual hallucinations...secluding...picking at imaginary things...crawling around on the floor...long history of mood swings marked by depression...During the interview at (this hospital) (name of Patient #10) was unable to give coherent responses to questions, therefore history was very limited coming mostly from the records received from (originating hospital).. Hospital Course: Friday evening (Name of Patient #10) was prescreened at an area jail and seen at (name of hospital ER) for medical clearance by (Name of physician Staff #3). After discussion with the (Initials of mental health hospital) on duty physician, (Name of Staff #3) decided that (Patient #10) was not medically stable and attempted to forestall the transfer of (Patient #10). A TDO was issued however and the Magistrate stated there was no legal mechanism to retract it. The police transported (Patient #10) to (initials of mental health hospital). The on duty told (Staff #3) during the first of two telephone conversations that he did not believe this individual was medically stable but that (initials of mental health hospital) could not refuse (Patient #10) due to Virginia law. On arrival (Patient #10) mental status was most consistent with delirium. The clinical diagnosis was supported by laboratories indicating:
a) acute renal failure (Creatinine 3.0, BUN 85)
b) liver failure (Bili 3.5, AST 704, ALT 513)
c) cardiac conduction abnormalities (Q waves, ST elevation, T wave inversion) were noted on EKG
d) Urine drug screen was positive for opiates, benzodiazepines, and tricyclics.

Physical exam was significant for mental status confusion, a questionable infected laceration on the left buttocks, tachycardia, and hypotension.

(Name of Physician) rapidly assessed the patient and referred him/her for evaluation at (name of local hospital). He/She was then admitted to (name of larger acute care hospital) and thus never seen by this author or members of the C team. His/Her TDO was held over until clinical findings at (initials of larger acute care hospital) confirmed that he/she was indeed very medically ill..."

The clinical record from the second acute care hospital was obtained for Patient #10. This record evidenced a"Consultation Report" dated 7/19/14 which revealed, "History of Present Illness: ...transferred to (name of hospital) from (name of second ED) for evaluation and treatment of apparent respiratory failure. By history the patient had a change in his/her mental status with increasing confusion and psychosis for several days prior to his/her admission. He/She been evaluated at the (name of ED patient first presented to)on 7/18/14 for apparent TDO order. The (name of mental hospital) subsequently returned the patient to (the second ED) where he/she was evaluated. The patient (sic) and acute renal failure, elevation of his/her liver function tests, and was confused and agitated...at the time of his/her admission, the patient was felt to have components of possible sepsis with hepatic failure, renal failure and metabolic [DIAGNOSES REDACTED]...he/she was intubated because of progressive respiratory dysfunction..."

"Discharge Diagnoses" documented on 7/29/14 were as follows:
1. Acute respiratory failure
2. Altered mental status
3. Severe [DIAGNOSES REDACTED] with ejection fraction of 20%
4. History of Alcohol abuse
5. End stage liver disease with septic cirrhosis
6. Severe sepsis
7. Acute episodes of hypotension
8. Acute renal failure
9. Hyponatremia
10. Troponinemia
11. Hypertension
12. Metabolic [DIAGNOSES REDACTED]
13. COPD (Chronic obstructive pulmonary disease)
14. Diabetes

On 8/6/14 at 4:00 p.m., the surveyor interviewed Staff #3 (ED physician). Staff #3 stated: "(Patient #10) was brought in for medical clearance. No history was given to me, but some of the nurses knew him and that he/she had a psych history with abnormal behavior with alcohol and substance abuse in the past. When I came in and saw him/her, he/she said he/she wasn't sure why he/she was in the ER (emergency room ). I asked him/her if he/she had any problems and he/she said "none". He/she was alert, and talking. His/her B/P (blood pressure) was slightly low 90/40 or something like that, and because the B/P was low, I expressed some concern about that...he/she was otherwise asymptomatic, so I told the nurse to get an EKG, CBC, Comprehensive panel, and tox (toxicology) screen. The EKG showed non-specific changes and a conduction defect, but there was no previous EKG to compare it to. I expressed concern about the low blood pressure but the patient was with no complaints. They drew the labs and then we got busy seeing other patients. At some time, I looked at the labs and the Creatinine was high, the BUN was high, the LFTs were abnormal and the ALT, AST and I think the phosphorous was elevated. I think the billirubin may have been elevated, but I am not sure about that right now. I was struggling with what to do about that and I got bust seeing other patients as I was deciding what to do. The blood pressure was rechecked and it was improved and the next thing I saw on the board for Room 3, the patient had been in Room 3, was there was a new patient in that room. I asked what happened to the patient who was in Room 3, and was told the Sheriff took him/her away. I said the patient was not medically cleared. If a patient comes in for clearance the accepting facility calls us and we get the labs and send them. The LFT's were normal in 2012 and I had no EKG to compare. There were no other blood pressures to compare. I then got a call of concern from the accepting hospital. I told them the patient was not medically cleared. My plan was to consult with them or another physician or Nephrologist but I hadn't made up my mind. I talked with the Behavioral Health person. He/she said he/she had saw the patient and the patient was hallucinating at home and running around naked in his home. I don't think that was a cause to TDO (Temporary Detention Order) someone but I didn't get that history. There were no complaints of chest pain. The Sheriff took him away and then I got a call from (Name of accepting facility) with concerns. This was about 7:30 or 8:00, when (name of facility) called and (name of physician) wanted to know how come I discharged the patient. The LFT and Creatinine was abnormal but I had a lab from 2012 that was normal. The (name) physician raised a concern of neurolepti[DIAGNOSES REDACTED] and wanted to know how the patient could be medically clear. I told him I did not clear the patient that I understood the patient had been taken by the Sheriff. We were both concerned. I called to find the patient and he/she was in the presence of the magistrate. I told them to bring him/her back but (name) of Behavioral Health said it was too late that they could not bring him/her back that he/she had already been TDO'd to (name of hospital) but that he/she (Behavioral Health assigned Staff # 5) would check with the magistrate but it was too late. I was told the Sheriff took the chart and where did I write medical clearance? I wrote in the diagnosis area, I never wrote medically cleared. I guess I need to clarify that. The nurse who accepted (name) and the Doctor called. I said "Listen, I did not medically clear this patient". I was told by behavioral health that the patient had been TDO'd and they could not bring him/her back but that (receiving hospital) could send him/her back out for an evaluation...we were busy in the ER and the nurse gave the lab and the paperwork to the Sheriff and discharged him/her. There was a misunderstanding with Behavioral Health and the nurse thought the patient was discharged ... What I wrote on the chart was a diagnosis, not a disposition..."

After review of the interviews and the clinical record for Patient #10, the survey team met at 8:45 a.m. on 8/7/14 and discussed the concern of Immediate Jeopardy regarding appropriate medical screening examinations under the EMTALA regulations. At 9:13 a.m. the Supervisor at the State Agency was contacted. With the Supervisor via telephone, Appendix Q was consulted and the team was in agreement with the concern for an Immediate Jeopardy issue. After consultation with the State Agency and notification to the Regional Office of CMS, the facility was notified by the survey team on 8/7/14 at 10:55 a.m., that an Immediate Jeopardy situation existed. The facility at that time was notified that an immediate plan of removal would be required.

At 4:45 p.m., on 8/7/14, the facility presented a plan of removal to the survey team. The plan of removal documented the following:

Strategy 1: Education
1.1 Identify opportunity for EMTALA & Behavioral Health Education to be completed by all ED providers.
1.2 Assignment of EMTALA Education for completion by all emergency room physicians from ECI.
1.3 Education to providers on appropriate selection of documentation tools.
1.4 ED physician to complete ECI education on medically clearing patients & EMTALA
1.5 ED providers and ED staff completion training on proper Temporary Detention Order (TDO) process.
1.6 EMTALA training for ED Nursing and ED Registration
1.7 ED Nursing to complete education pertaining to proper patient reassessment and documentation of reassessment.
Strategy 2: Policy
2.1 Development of a mental health patient management procedure for DCH (Hospital initials)
Strategy 3: Documentation
3.1 Immediately discontinue use of electronic Patient Rights and Responsibilities form.
3.2 Immediately begin using paper Patient Rights and responsibilities form that includes all needed fields to clearly define relationship of person signing form. Rights and responsibilities forms to be completed correctly to include accurate relationship status of person signing forms.
3.3 Development and deployment of a Pre-disposition checklist of all required elements for mental health.
3.4 Development and deployment of a clinical staffing plan to determine staffing levels to meet patient demand.
3.5 (Name of Behavioral Health) documentation required to be placed on all behavioral health patients charts prior to discharge.
3.6 Provider documentation of patients disposition/condition required on all charts prior to discharge.
3.7 All transfer forms competed appropriately.
Strategy 4: Performance Improvement
4.1 Daily all (Hospital initials ED) Mental Health patents charts reviewed for complete, appropriate and accurate documentation by Director of Patient Care Services and Medical Director.
4.2 70 (initials of ED) charts will be reviewed monthly for complete, accurate and appropriate documentation.
4.3 Development of monthly Behavioral health review Committee (names of members)
4.4 Monthly meeting with (behavioral health) to review results of chart reviews
4.5 Root Cause Analysis completed (Action Plan) by Friday August 15, 2014.

Completion dates for Immediate Removal: 8/7 and 8/8/14.

On 8/7/14 at 5:00 p.m., the facility was notified of the acceptance of the plan of removal.

2. Patient #1 was seen on 5/4/14 for a laceration of the left wrist and depression. Patient #1 was seen by the Community Services Board/Behavioral Health Authority on 5/4/14/ and a TDO (Temporary Detention Order) was issued for the patient to be admitted to an inpatient psychiatric facility. The physician's assessment evidenced: "discharged to the care of police". There was no Transfer Authorization Form on the Medical Record.

Patient #8 was seen on 5/23/14 for depression and suicidal ideation. Patient #8 was seen by the Community Services Board/Behavioral Health Authority (CSB/BHA) on 5/23/14 and agreed to voluntarily be admitted to (name of psychiatric treatment center). The physician's assessment stated, "discharged to home" . There was no Transfer Authorization Form on the medical record.
Patient #10 was seen on 7/18/14 for medical clearance. Patient #10 was seen by the Community Services Board/Behavioral Health Authority (CSB/BHA) on 7/18/14 prior to being seen at the facility. A Temporary Detention Order (TDO) was issued for Patient #10 to be admitted to (initials of psychiatric hospital). The physician's assessment stated, "discharged condition stable" . No disposition was documented in the medical record. The pre-screening was not on the medical record at the time of the record review. There was no Transfer Authorization Form on the medical record.
Patient #11 was seen on 6/3/14 for depression. Patient #11 was seen by the Community Services Board/Behavioral Health Authority (CSB/BHA) on 6/3/14 and a Temporary Detention Order (TDO) was issued for Patient #11 to be admitted to (initials of psychiatric hospital). The physician's assessment stated, "discharged to law enforcement" . There was no Transfer Authorization Form on the medical record.
Patient #14 was seen on 6/19/14 for suicidal ideations. Patient #14 was seen by the Community Services Board/Behavioral Health Authority (CSB/BHA) on 6/19/14 and a Temporary Detention Order (TDO) was issued for Patient #14 to be admitted to (name of psychiatric treatment center). The physician's assessment stated, "discharged to home" . There was no Transfer Authorization Form on the medical record.
Patient #17 was seen on 6/24/14 at 23:49 for headache - attempted to hang self. Patient #17 signed discharge instructions on 6/25/14/at 01:25 (1:25 a.m.). The nursing assessment report stated the patient was discharged back to (name of jail). . The physician's assessment stated, "discharged to home" . Patient #17 was seen by the Community Services Board/Behavioral Health Authority (CSB/BHA) on 6/25/14 and a Temporary Detention Order (TDO) was issued for Patient #17 to be admitted to (initials of psychiatric hospital). The CSB pre-screening form stated, "Clt. (Client) seen at (initials of local emergency room ) last night and medically clearance was not completed. Clt presented flat, limited eye contact this am. Reports she/he will continue to try to harm self because she/he feels her/his family would be better off without her/him .....Accepted at (initials of psychiatric hospital) without medical clearance. There was no Transfer Authorization Form on the medical record.
Patient #21 was seen on 7/22/14 for mental problems and anxiety. Patient #21 was seen by the Community Services Board/Behavioral Health Authority (CSB/BHA) on 7/22/14 and Patient #21 was agreeable to a voluntary inpatient admission . On 7/22/14. Patient #21 was to be transported by family. The physician's assessment stated, "stable", but does not indicate where or to whom Patient #21 was discharged . There was no Transfer Authorization Form on the medical record.
Patient #22 was seen on 7/28/14 for depression. Per the Clinical Notes Patient #22 was seen by the Community Services Board/Behavioral Health Authority (CSB/BHA) on 7/28/14 however there was no evaluation or pre-screening on the medical record at the time of the review (8/7/14). The clinical notes state, "(name of Behavioral Health employee) has been here and advises the Pt. is going voluntarily to (name of treatment center) to be admitted there ....discharged to ...family" . The physician's assessment stated, "discharged to home" . There was no Transfer Authorization Form on the medical record.
Patient #23 was seen on 7/31/14 for anxiety and panic attacks and acute psychotic episode. Per the Clinical Notes Patient #23 arrived with (name of Behavioral Health Employee) and family. There was no indication an assessment was performed by the Community Services Board/Behavioral Health Authority (CSB/BHA) on 7/23/14 for Patient #14. The physician's assessment stated, "Transferred to custody of (Department of Behavioral Health) to TDO". There was no Transfer Authorization Form on the medical record.
Patient #25 was seen on 8/3/14 for alcohol abuse. Patient #25 was seen by the Community Services Board/Behavioral Health Authority (CSB/BHA) on 8/3/14 and a Temporary Detention Order (TDO) was issued for Patient #25 to be admitted to (name of psychiatric hospital). The physician's assessment stated, "discharged to MH (mental health) and deputy" . There was no Transfer Authorization Form on the medical record.
Patient #4 was seen on 5/16/14 for the diagnosis of [DIAGNOSES REDACTED]#4 was transferred to ICU (Intensive Care Unit) at (initials of acute care hospital) on 5/16/14. The transfer form does not indicate if Patient #4 was transferred by Patient #4's consent. The form was not signed by Patient #4. The signature of the responsible person did not indicate who the person was or their relationship to Patient #4. The form did not indicate if accompanying documentation was sent with Patient #4, faxed or transported. The form did not indicated the date and time of the actual transfer.
On 8/7/14 at approximately 10:30 A.M. Staff Member #2 stated, "Do we need to complete a transfer from on every person who leaves here and goes somewhere else even when the CSB says they have to go?"
Patient # 2 was seen on 5/5/2014 for medical clearance. The Community Services Board (CSB) saw Patient # 2 prior to Patient # 2 being seen at the facility. A Temporary Detention Order (TDO) was issued for Patient # 2 to be admitted to (initials of treatment center). The physician's assessment of discharge condition was left blank. No disposition was documented on the physical examination record. The pre-screening was not on the record at the time of the record review. There was no Transfer Authorization Form on the medical record.

Findings of the survey were discussed with the facility Administrator, Director of Patient Care, Quality and Risk Management, the Chief Executive Officer, and the Chief Nursing Officer on 8/7/14.

The survey team reviewed the ' Emergency Medical Treatment and Patient Transfer ' Policy and Procedure (P&P). The policy had a creation date of 7/1/99 with the most recent review and effective date of 11/1/13.
The P&P defined Transfer as, " The movement (including the discharge) of an individual outside the hospital ' s facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the hospital, but does not include such a movement of an individual who has been declared dead or leaves the facility without the permission of any such person. "
Stable for Transfer is defined as, " If the patient is transferred from one facility to a second facility and the treating physician attending to the patient has determined, within reasonable clinical confidence, that the patient is expected to leave the hospital and be received at the second facility, with no material deterioration in his/her medical condition; and the treating physician reasonably believes the receiving facility has the capability to manage the patient ' s medical condition and any reasonable foreseeable complication of that condition. For psychiatric conditions, the patient is considered to be stable for transfer when he/she is protected and prevented from inuring himself/herself or others. "
Policy: A hospital must not transfer a patient to another facility, unless the hospital does not have the services or equipment needed to stabilize the patient or the patient/legal representative requests a transfer.
Procedure: Prior to discharge, if present, must inform the patient or legal representative of the need for transfer.
Prior to transfer, the physician must confirm positive acceptance by a physician at the receiving facility and confirm the receiving physician ' s name. The physician must also complete, or confirm the information contained in, the physician-required sections of the Transfer Authorization Form.
Prior to transfer, the RN (registered nurse), Case Manager, or Social Worker must confirm positive acceptance by the receiving facility, including bed availability and qualified staff awaiting patient ' s arrival. The date and time of confirmation must be documented in the Transfer Form.
Prior to transfer, QMP shall provide medical treatment within the hospital ' s capacity to minimize the risks to the patient ' s health ...The physician shall determine the appropriate mode of transportation (including any accompanying equipment and personnel).
In order to verify and document appropriate transfer the following forms must be completed and the following records must be kept (unless noted to be inapplicable to the patient, as described in the P&P: Transfer Authorization Form; Pertinent Medical Information; Physician Order; Emergency Commitment Form; Certificate of Medical Necessity for Ambulance Transportation.
Quality of Care Review:
1. Each hospital shall periodically review its transfers to identify opportunities for improvements. The review shall include, but not be limited to, a determination of whether the following requirements for transfer are being satisfied:
a. Documentation reflects patient ' s condition on transfer (refer to Transfer Authorization Form for stable/unstable).
b. The physician has signed a certification stating that based on the assessed needs of the patient at the time of transfer, the medial benefits reasonably outweigh the increased risks to the patient (and in the case of labor, to the unborn child) caused by such a transfer (or such certification was signed by the QMP at the time of the transfer and subsequently counter-signed by the physician).
c. The receiving facility has available space and qualified personnel and has agreed to accept the patient (refer to Transfer Authorization Form).
d. Documentation reflects all medical records related to the emergency condition are sent to the receiving facility (refer to Transfer Authorization Form).
e. The transfer is affected through qualified personnel and transportation equipment (refer to Transfer Authorization Form).
f. Results of the reviews shall be reported to the Medical Staff and to the Administration.