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.

Based on interview and observation, the hospital failed to conspicuously post EMTALA signage as required, and post also in languages understood by a significant community population of Spanish and Russian.
Tour of the emergency department (ED) revealed the main entry point of the ED as having a vestibule area in which multiple signs are posted. The EMTALA signage was observed to be posted only in this vestibule area in a large (approximately 2 foot by 2 foot) frame which incorporates a wide mat, effectively reducing the actual EMTALA information to the approximate size of a standard piece of paper, 11 " by 8 ? " .
Interview with administrative staff on 10/29/13 at approximately 3 pm reveals that the hospital has significant Spanish and Russian community populations. However, no EMTALA signage was noted to address the languages of these populations.
In summary, while the hospital does have an EMTALA sign posted, it is not conspicuous, nor is it posted in languages known to be of significance within the community.

Based on interviews, observations, review of medical records, and other pertinent documentation for patient #1, the hospital failed conduct an emergency medical screening.
Patient #1 is a [AGE]-year-old male who presented to the emergency Department (ED) of Northwest hospital on [DATE] at 4:38 pm accompanied by police, and following his report of suicidal ideation with a plan to cut his wrists. Additional self-reports revealed that he was having auditory hallucinations and had just been released from jail. Patient #1, who has a history of a mental illness.
While patient #1 was initially noted as appearing to respond to voices, a Crisis Intervention Specialist (CIS) evaluation of 10/20 at 4:35 am found patient #1 to deny suicidal/homicidal ideations, hallucinations, and racing thoughts. Patient #1 stated that he did not want to stay at the homeless shelter that was provided him by the jail. A psychiatrist was consulted and patient #1 was found not to have an emergency medical condition. The hospital discharged him with referrals for follow-up with Healthcare for the Homeless, and his probation appointment of 10/21. Patient #1 was given instructions to return if his condition worsened. He was discharged on [DATE] at 7:03 am without medication or prescriptions, and left the ED on foot.
On 10/20/2013 at 8:14 am, approximately one hour later, patient #1 returned to the ED of Northwest Hospital on an emergency petition for psychiatric evaluation accompanied by police, following reports that patient #1 had purposefully thrown a match into a waste basket at a local pharmacy. Additionally, Patient #1 reported that he was hearing voices, which had told him to do so.
According to an RN note of 10/20/13 at 8:56 am, " (County Police) took patient back after Psych CIS (Crisis Intervention Specialist) (name of CIS) told police he needed to be arrested not EP ' d (emergency petitioned)."
The police left with Patient #1 and took him to another hospital . Per the documentation from the second hospital to which patient #1 was taken, the police officer who accompanied patient #1 stated that patient #1 was discharged from Northwest Hospital today, who " ...refused to accept him back. "
The receiving hospital subsequently found patient #1 was due for his depot antipsychotic injection. While he denied suicidal and homicidal ideation, he was determined to have an emergency medical condition based on fleeting auditory command hallucinations to " burn things down " and his report that the voices only stop after he complies with the command. Patient #1 agreed to a voluntary admission and was transferred to an accepting hospital.
In summary, patient #1 presented on an emergency petition, escorted by police, and was required to have an emergency medical evaluation. However, no emergency medical evaluation was conducted as required for all persons presenting to an emergency department. Consequently, the hospital failed to meet regulatory requirements for the emergency medical evaluation.
Based on a review of Behavioral Health Logs of requests to transfer medically-cleared patients who have been assessed to have emergency medical conditions, it is determined that patient #2 was refused transfer from another hospital based on Northwest belief that she was no longer suicidal and therefore did not meet criteria.

Northwest Hospital Behavioral Health Unit (BHU) has a total of 23 beds. The hospital maintains an admission referral log to track referrals from other hospitals. The BHU Admission Referral Log (ARL) from 8/1/2013 to 10/29 was reviewed and it revealed emergency department (ED) referrals inclusive of the surveyed hospital, its system sister hospital , and 19 other referring hospitals. The log revealed that on 9/25 and 9/26, the BHU had a census of 22. The log had a referral from one hospital but there was no documented explanantion why the patient was not accepted. Another hospital made two referrals for the same patient during this time frame. The log indicates that the patient who was suffering from depression was not accepted because "Pt does not meet criteria."

Records reviewed from the ED that was treating patient #2 revealed that patient #2 was given a diagnosis of overdose, hypoxia and recurrent major depression. Patient #2 initially refused admission to a psychiatric hospital, and was involuntarily certified for inpatient stabilization. A second psychiatric assessment was conducted while patient #2 was in the ED. At that time she agreed to a voluntary admission. The social worker then placed calls to area hospitals, and on 9/24 at 3:30 pm documented that Northwest "may have a female bed available."

On 9/26 at 11:34 am, the social worker wrote in part, "SW informed by the Charge RN at Northwest that pt has been denied for not meeting criteria as she is no longer suicidal." At that time the transferring ED still believed the patient required inpatient stabilization even if the patient agreed to be voluntarily admitted for psychiatric services. It is unclear why Northwest determined that patient #2 no longer had an emergency medical condition where both the emergency department physician and the psychiatric assessments determined a need for inpatient stabilization.

In addition to the above case, there were additional entries in the log that lacked evidence that the hospital could not have accepted an admission such as :

On 8/27 the BHU census was 19. A referral from one hospital was not admitted due to " acuity, " and a referral from another was not admitted due to "1" admission pending, although the BHU still had 3 beds left.

On 9/9, the starting census was 17 when a referral from another hospital for a patient with suicidal ideation with no plan was made and not admitted due to "does not meet criteria."
On 9/27 with a BHU census of 21, a referral from Hospital #20 was not accepted with no explanation.

Based on the investigation, Northwest failed to accept patient #2 because she was no longer suicidal, despite the fact that patient #2 still required hospitalization for further stabilization.