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.

BLUE RIDGE REGIONAL HOSPITAL, INC 125 HOSPITAL DR SPRUCE PINE, NC April 10, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on hospital policy reviews, dedicated emergency department (DED) record reviews, treatment center documentation, physician, staff, and law enforcement officer interviews the hospital failed to comply with 42 CFR 489.20 and 42 CFR 489.24 by failing to provide an appropriate transfer for 1 of 7 patients (#3) who presented to the hospital's DED with an emergency medical condition (EMC) and was transferred.

The findings include:

The hospital's DED staff failed to provide an appropriate transfer by failing to ensure the patient was transferred to a facility with comparable resources and capabilities as Hospital A or to a hospital with specialized psychiatric capabilities (higher level of care); ensure physician certified that the medical benefits of transfer outweighed the risks to the patient; failing to document the receiving hospital had available space and qualified personnel and had accepted the patient for transfer; failing to document that all medical records related to the patient's EMC were sent to the recipient facility for 1 of 7 sampled DED patients (#3) transferred with an EMC.

~Cross refer to 489.24(e)(1)-(2), Provisions of appropriate transfer - Tag A2409.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy review, closed medical record reviews, treatment center documentation review, physician, staff, and law enforcement officer interviews, the hospital's dedicated emergency department's (DED) staff failed to provide an appropriate transfer by failing to ensure the patient was transferred to a facility with comparable resources and capabilities as Hospital A or to a hospital with specialized psychiatric capabilities (higher level of care); ensure physician certified that the medical benefits of transfer outweighed the risks to the patient; failing to document the receiving hospital had available space and qualified personnel and had accepted the patient for transfer; failing to document that all medical records related to the patient's EMC were sent to the recipient facility for 1 of 7 sampled DED patients (#3) transferred with an EMC.

The findings include:

Review of hospital policy (in effect on 02/15/2014) "Transfer of a Patient (Out of the Facility)" No: 5PC.RS3695, last reviewed 01/14, revealed "Purpose: To transfer patients to facilities that is capable of providing care and services not provided by (Hospital A name). When the patient's care needs exceed the hospital's services, physician or equipment capacities, the patient will have transfer arrangements made per physician. Hospital policy transfer directions will be followed. Documentation will be on the following: 1. Physician Transfer Order and Transport Request Form. 2. Certification of Transfer Form 3. Physician Certification of Medical Necessity for Ambulance Transport (EMS Form) Documentation will be on the above of whom the accepting/receiving physician is and that he is aware of the transfer and patient condition. The patient primary care nurse will call report to the receiving facility and this will be documented in the patient's medical record. All patients being transferred from ... will have the above forms filled out and sent with patient . ... The transfer form must be completed in its entirety to maintain compliance with 'EMTALA, DHHS, CMS and OIG'. ... Responsibilities: The Hospital is responsible for providing essential life saving measures, stabilizing the patient and preparing the patient for transfer in such a way that does not compromises [sic] the condition of the patient during transport. ... the decision to transfer is made by the attending physician. The physician must contact the receiving physician and discuss the transfer with him/her, unless involuntary commitment. (See page 3 - last paragraph). The nurse or unit clerk may place the call for the physician, but the physician must speak personally with the receiving physician. This duty cannot be delegated. Assessment: ... The nurse must ascertain whether or not the receiving facility has been informed of and agreed to accept the transfer. The nurse is responsible for contacting ... house supervisor at any other specified hospital. The nurse must give the following information to the receiving facility when calling report: 1. Patient's name and age 2. Patient's diagnosis 3. Patient's present condition 4. To which physician's service the patient will be going 5. Estimated time of arrival and mode of transfer 6. Brief summary of treatment already rendered 7. Any other pertinent information 8. The 'Hand-Off Communication' policy can be used as a reporting tool. 9. Fax copy of: a. Physician Transfer Order Form and Transport Request Form b. Certification of Transfer c. Demographic sheet Document all treatment, current vital signs and all information on the patient's medical record and make a copy to be sent with the patient. Also, copies of all available lab reports and x-rays should be sent. Further, document on the Transfer Form the disposition of the patient and notification of receiving physician and facility, risks, benefits, alternatives and condition of patient, accepting M.D.'s name, reason for transfer, authorization of transfer and release of copies, signature of M. D., transferring nurse, signature patient/legal guardian or responsible party, which is all included in the Consent and Authorization for Transfer Form. The Physician Transfer/Transport Request Form must also be completed with diagnosis, condition of patient, emergency or non-emergency/routine, MD receiving patient, code status, patient location, transfer to, mode of transportation, type of attendant, mode/support/treatment/equipment needed during transport, MD/RN signature. All blanks must be filled in on both the above sheets. ... Policy: In response to the patient's request and need, the organization provides care that is within its capacity. When the organization cannot meet the request or need of care, the patient may be transferred to another facility when medically permissible. If a patient is transferred to another facility by private vehicle, a transfer sheet with consent form and all appropriate chart information, labs, x-rays, etc. (Copy) must accompany the patient. The attending physician determines and orders for the patient to be transferred from the .... Hospital to another organization. The patient is not transferred until the receiving organization has consented to accept the patient and the patient is considered sufficiently stabilized for transport. Under no circumstances is a patient to be transferred from the .... Hospital without physician-to-physician referral, unless involuntary commitment patient. (See page 3-last paragraph). The attending physician shall determine Emergency medical Condition (EMC) or No Emergency Medical Condition after patient exam. The attending physician shall also determine: patient is stable or patient is unstable. The reason for transfer, risk and benefits for transfer and receiving facility and receiving MD shall be determined and all documented by the attending MD. A copy of all appropriate records shall be transferred with patient. This will include the current Medical Record, Laboratory, X-rays, EKG, copy of all transfer forms and all other pertinent records. The Nurse's notes shall include that a telephone report was given to the receiving facility and that the bed is available. The Registered Nurse should document name and title of person that report was given to. The patient's physician of should include the name of the physician receiving the patient. Physician to physician referral is done except on involuntary commitment patients. Mental Health personnel, who consult on these patients, will make appropriate arrangements to receiving facilities ... and agreement of acceptance and give report to the receiving facility regarding patient's condition and pertinent information. The State Law is satisfied when representatives of physicians talk with one another. Staff will determine M.D.-to-M.D. contact under certain circumstances as cases arise. All transfer forms shall be filled out on all patients transferred to another facility i.e. Tertiary Care Center or involuntary committed patients to psychiatric facilities. The nurse assures all blanks on Physician Transfer Order Form/Transport Request Form and Consent and Authorization for Transfer Form are filled in and addressed. The nurse is also responsible for Section V and VI-accompanying documentation, report given, IV's prior to transfer etc., and patient consent to transfer signature, etc. ... "

Hospital A, closed DED record review on 04/09/2014 for Patient #3 revealed a [AGE] year old male who presented ambulatory via private transportation to the DED on 02/14/2014 at 1819. Review revealed the patient was triaged by a Registered Nurse (RN) at 1827. Review of "Rapid Triage Assessment" documentation at 1827 revealed a chief complaint of "Suicidal ideations." Review of triage nurse documentation at 1832 revealed "Stated Reason for Visit: Pt. (Patient) reports feeling like hurting himself or someone else, states this [sic] has been having these thoughts for years." Further review revealed "Chief Complaint: HARM SELF/OTHERS." Review revealed "Risk for Mental Health Emergency: Yes." Review revealed the patient's vital signs (VS) were assessed as: temperature (T) 97.6 degrees Fahrenheit, oral; heart rate (HR) 80; blood pressure (BP) 114/66; respiratory rate (RR) 20; oxygen saturation (O2 Sat) 95% on room air (RA). Review revealed a pain assessment was performed using a numerical pain scale of 0-10 (0 pain free, 10 worst pain) with a reported pain rating of 8. Review revealed a past medical history (PMH) of Anxiety, Bipolar, Depression, Post Traumatic Stress Disorder (PTSD), and Substance abuse. Review revealed the patient was assigned as triage acuity 3-urgent. Review of an "ED Assessment" performed at 1853 by a RN revealed documentation of a "Mental Status Assessment" with Mood: Flat Affect; Thought Process: Concrete; Behavior: Appropriate; General Appearance: Appropriate, Clothes Appropriate, Well Groomed; and a "Neurological Assessment" as Orientation: Oriented X4 (person, place, time, event/situation); Level of Consciousness: Alert, Awake; Follows Commands: Yes; Communication: No Deficits.

Review of DED nursing documentation revealed at 1929: "(name) (telephone number) Mobile crisis. RHA (contracted Mobile Crisis Management [MCM] service) called and states enroute to hospital. At 1931 "MD into speak with pt. Pt anxious at this time." At 2015 "RHA out of room, medication order noted ... ." At 2111 vital signs were reassessed as HR 75, BP 155/86, RR 20, O2 Sat 95% on RA. At 2112 "pt voices feeling more relaxed s/p (status post) medication states no longer feels like knots in his stomach." At 2132 "petition for involuntary signed by MD." At 2205 "Pt requesting pain medication as previously prescribed at home. V.O (verbal order) with R.B (read back) received for prn (as needed) medication for pain and muscle relaxation." At 0017 (02/15) vital signs were reassessed as T 97.6 degrees F., HR 72, BP 145/95, RR 16, O2 Sat 95% on RA. At 0019 "Pt with ER (emergency room ) hold orders, bed requested." At 0031 "Transfer via w/c (wheel chair) to ED hold Room 207 (located on the Medical-Surgical Floor)."

Review of MSE (medical screening examination) documentation by Physician A at 1915 revealed "HPI (History of Present Illness)" with a chief complaint of suicidal thoughts with gradual onset, frequent, long-standing with increased intensity last few days. Review revealed suicide intent with thoughts of suicide often, moderate severity, and chronic anger, rage. Review revealed associated symptoms of being angry and frustrated. Review revealed suicidal thoughts with a specific plan. Review of Systems (ROS) revealed chronic joint pain. Review of a Past History revealed, prior suicide attempt by hanging, depression, bipolar disorder, PTSD. Hepatitis C and chronic musculoskeletal pain. Review of Physical Exam documentation revealed - General Appearance: no acute distress, alert, anxious; NEURO/PSYCH: mental status - mood/affect normal; tearful, hostile at times. Review revealed, "For suicide attempts On direct query patient admits continued consideration of suicide as an option." Orientation - normal x4; cranial nerves - normal (2-10); sensory motor - normal motor response, normal sensory response, normal reflexes/normal gait. Review of "PROGRESS" revealed "Evaluate in ED by RHA/Mental Health" and "Involuntary Commitment (IVC) executed." Review of "Clinical Impression" revealed suicide ideation and patient is harm to self/others. Disposition Decision Time 0015 (02/15). Review of Physician's Orders revealed an order for a Mental Health Consult.

Review of a contracted Mobile Crisis Management (MCM) service, "Crisis Services Intake and Outreach Assessment" for Patient #3 dated 02/14/2014 at 1930 by a MCM staff member revealed "Purpose of Contact/Consumer Presentation" with depression, feelings of guilt/worthlessness, helpless/hopelessness, Suicidal/Homicidal Ideation, anxiety, flight of ideas, and irritability indicated by check marks in adjacent boxes. Review revealed "Comments 'I just can't take it anymore ... I have pain all over last night I wanted to kill myself '." Review revealed "Danger to self " with suicidal ideation and plan/intent/means indicated by check marks in adjacent boxes. Review revealed "Comments 'I have lots of ways, I could tell you a bunch of different ways I would do it.'" Review revealed "'I tried to hang myself before.'" Review revealed "Danger to others" with homicidal ideation indicated by check mark in adjacent box. Review revealed "Comments 'Sometimes I feel like it.'" Further review revealed "Overall Risk Assessment Has Plan, history of attempt" with "High Risk Serious mental health problems present possibly including symptoms of psychosis. Have clearly identifiable risk characteristics such as imminent thoughts of plans relating to self harm to others or self. May lack capacity and competence to consent to or refuse on going care and treatment. Mental state will certainly deteriorate without intervention and will almost certainly be physically vulnerable. Refusal of crisis intervention including further evaluation or inpatient care. Recommendation of IVC when appropriate further evaluation and/or inpatient care" indicated by a check mark in adjacent box. Review revealed "Interim Diagnosis or Current Diagnosis" of Axis I 296.90 (Mood Disorder, Not otherwise specified) et al. Review revealed "Services Needs and Recommendations" with inpatient and other crisis inpatient indicated by check marks in adjacent boxes. Review revealed "MCM Action Taken" with "Other Screened for NDC (Treatment Center A) bed on 2/15/14." Further review revealed "W/H (will have) to remain in ED until placed."

Review of a "Examination and Recommendation to Determine Necessity for Involuntary Commitment" petition dated 02/14/2014 at 1930 signed by Physician A, revealed "SECTION I - CRITERIA FOR COMMITMENT" with "Inpatient It is my opinion that the respondent (Patient #3) is [check mark in box] mentally ill [check mark in box] dangerous to self. ..." Review revealed "SECTION II - DESCRIPTION OF FINDINGS" revealed "Extensive psych history with prior suicide attempts off all psych meds. States formal suicide thoughts, potential plan. Has ways and means to end his life."

Review of "Findings and Custody Order Involuntary Commitment" dated 02/14/2014 at 10:40 PM revealed "FINDINGS The Court finds from the petition in the above matter that there are reasonable grounds to believe that the facts alleged in the petition are true and that the respondent (Patient #3) is probably (Check all that apply) [X in box] 1 mentally ill and dangerous to self or others. ..."

Continued review of MSE documentation on 02/15/2014 at 1630 by Physician B revealed "Pt awaiting placement to psych facility. Nursing reports no problems. Pt states he feels a little better since starting Zyprexa but he still admits to suicidal/homicidal thoughts. Will continue to hold until placement."

Review of Medical-Surgical unit nursing documentation revealed at 0040: "Pt arrived on the floor from ER by stretcher ... accompanied by ... security. Discussed IVC and procedure with pt, he verbalized understanding. Pt alert and oriented, answers questions appropriately ... ." At 0050 "VS BP 153/96 ... ." At 0105 "Pt requested IM (intramuscular) Zyprexia [sic] (a Thienobenzodiazepine - used for the treatment of schizophrenia, acute treatment of manic or mixed episodes associated with bipolar I disorder and maintenance treatment of bipolar I disorder) he states 'I feel like I am nutting [sic] up' appears agitated, pacing in room. Med (medication) given in left deltoid ..." At 1030 "... PRN Zyprexa given per pt request ... Pt states 'pill helps me relax.'" At 1506 "Vital signs BP - 128/82 ... ." At 1924 the patient's BP was reassessed as 153/99 with "RN aware of BP" documented. At 1930 "Pt c/o pain ... informed pt I would call ER physician about his pain ..." At 1950 "ER physician (Physician C) called about Pts c/o pain & new orders received. (Name) from (contracted MCM service) called stating pt had been approved for 'face to face' admission screening 'for (Treatment Facility A - Not a licensed hospital) in Asheville, and that no further paperwork was to be faxed, only dispatch called for police transport + (and) all pts 'chart' be copied & sent with patient." At 2115 "Patient informed of his acceptance for 'face to face admission screening' for (Treatment Center A). Pt seemed agitated, stating 'I'll never do this mess again' Pt requests pain medication again & I informed him of new orders received from Dr. (Physician C) & I will get them to him as soon as I can Also @ (at) this time dispatch is called to ask for police to transport pt and the dispatcher states they will have someone call us back with an estimated time a deputy will be picking up the patient." At 2130 "Pt medicated for c/o pain per MD order. Vital Signs ... BP 187/120 - will recheck B/P NAD." At 2150 BP rechecked 152/100 @ this time Pt states 'its cause I'm hurting & I just want to get out of here.' ..." At 2215 "(XYZ) County Sheriff's dept (department) called to inform staff they were sending an officer to transport pt. Pt informed & explained the expected process for his transport. Pt still seems agitated, pacing the room & again stating 'I'll never do this again.' Pt denies any other needs at this time." At 2245 "Pt continues to pace in room, standing in doorway and appears still agitated. ..." At 2355 "Sheriffs Deputy to pick up patient, copies of all pts paperwork given to deputy. The transport process once again explained to pt & he still is agitated & pacing the floor in his room Pts belongings sent with wife. Deputy, patient & pts wife leave the floor with all paperwork & belongings."

Review of Hospital A medical records failed to reveal any available documentation that Patient #3 was transferred to a hospital with comparable resources and capabilities as Hospital A nor to a hospital with specialized psychiatric capabilities (higher level of care). Further review failed to reveal documentation the DED physician and/or other QMP (Qualified Medical Person) completed a physician's certification for transfer form and/or certified that the medical benefits of transfer outweighed the risks to the patient; obtained the patient's consent for and/or refusal for transfer; ensured the receiving facility had space and qualified personnel available and agreed to accept the patient; copies of ALL pertinent medical records available at the time of transfer were sent to the receiving hospital, nor that the nursing staff called report to the recipient facility.

Review of a "Crisis Preliminary Screening Information" form dated 02/14/2014 at 0845 (faxed to Hospital A from Treatment Center A on 04/09/2014 at 1619), revealed documentation of preliminary screening information for Patient #3. Review of the form revealed, "02/15/2014 IVC'd at (Hospital A name) All hospital referral papers requested at 0830." Review of the form revealed documentation (not dated, or timed) by a RN of vital signs being obtained on Patient #3 after presentation to Treatment Center A (after departure from Hospital A on 02/15/2014 and while in the custody of XYZ Sheriff's Department Deputy #1). Review of the vital signs revealed a BP 208/129 (elevated), a Pulse 82, and a O2 Sat 97%. Further review revealed "Follow-up information: Client was an ER hold never inpt (inpatient). Per (Treatment Center A staff name) send to (Hospital B name)."

Hospital B, closed record review on 04/10/2014, revealed Patient #3 (MDS) dated [DATE] at 0141 (1 hour 46 minutes after departure from Hospital A) in the custody of law enforcement (Sheriff Deputy #1). The patient was triaged by a RN at 0215 with a chief complaint of "Behavioral Health Concern." Review revealed a "Stated Reason for Visit: Patient states that he went to the hospital in Spruce Pines requesting medication since he has been off his psych meds and was brought here two days later. Denies SI/HI (suicidal ideation/homicidal ideation)." Review revealed the patient's initial triage vital signs were assessed as T 97.6 degrees F. oral, BP 169/119 (elevated), P 76, RR 20, O2 Sat 93%. Review revealed the patient was assigned an acuity level of 2 - Emergent. Review revealed a MSE was performed by a QMP with a diagnosis of Suicidal Risk and Bipolar affective disorder. The patient was subsequently admitted to the inpatient psychiatric unit of Hospital B and was discharged on [DATE] (9 days after admission) with a discharge diagnosis of 1. Bipolar Disorder Type I, most recent episode mixed and moderate without psychotic features. 2. Anxiety disorder NOS with features of generalized anxiety disorder, panic and post traumatic stress disorder. Further record review failed to reveal documentation of copies of ALL pertinent medical records available at the time of transfer from Hospital A, to include a completed physician's certification for transfer form or documentation that the DED physician from Hospital A certified that the medical benefits of transfer outweighed the risks to the patient; documentation of the patient's consent for and/or refusal for transfer; documentation the receiving hospital had space and qualified personnel available and had agreed to accept the patient nor documentation the nursing staff from Hospital A called report to the recipient facility.

Interview on April 9, 2014 at 1617 with Physician C, revealed he was the attending DED physician on duty, February 15-16, 2014 from 1900 to 0700 (Night shift), when Patient #3 was transferred from Hospital A to Treatment Center A. Interview revealed he received verbal report from Physician B at the change of shift. Interview revealed he was made aware that Patient #3 was awaiting psychiatric placement and was being held in the ED Hold Room (207) on the second floor (Medical-Surgical unit). Interview revealed when a patient is placed on the second floor as an "ED hold," the patient is still under the care of the ED physician and is still considered an ED patient. Interview revealed the ED is responsible for the care of the patient. Interview revealed when a patient is placed on the second floor, the second floor nursing staff provide nursing care for the patient. Interview revealed patients placed in the ED hold room on the second floor are "rounded on" at least once per shift by the ED physician. Interview revealed he did not evaluate or round on Patient #3 from 1900 to 2355, before the patient's transfer. Interview revealed he did not round on the patient during the shift, because the patient had already left the hospital. Interview revealed "I did not know the patient was off the floor" until after the ED received a telephone call from "down in Asheville at the (Treatment Center A)." Interview revealed a staff member from Treatment Center A called back to the ED and spoke with (ED RN #1). Interview revealed the (Treatment Center A) staff member stated that a "Cobra Form" had not been completed and sent with the patient. Interview revealed the Treatment Center A staff member told (ED RN #1) that the patient was sent to the ED at (Hospital B) because they (Treatment Center A staff) felt his blood pressure was unstable. Interview revealed in the past, the (contracted MCM service) staff, would keep the physician informed of the placement process and facility search. Interview revealed, normally the patient would have been brought back to the ED from the second floor, before transfer. Interview revealed a final examination would have been completed, the physician would then "sign off" on the patient, and complete all of the transfer forms. The patient would then be transferred. Interview revealed he did not complete or sign a physician's certification for transfer form for Patient #3. Interview revealed "I am the only one who would have signed the form no one else could do it." Interview revealed he did not explain the risks or benefits of transfer to the patient. Interview revealed he did not receive the patient's written consent for transfer. Interview revealed he does not know if any records were sent with the patient to Treatment Center A. Further interview revealed he was aware the patient's blood pressure had been elevated, but did not recall discussing exact numbers with the nurse. Interview revealed the patient's blood pressure, was most likely elevated due to him being agitated and emotionally labile. Interview revealed "an emergency medical condition existed in the form of a mental health issue, the patient was physically stable." Interview revealed Treatment Center A is a substance abuse and detoxification center in Asheville. Interview revealed it is not a hospital. Interview revealed Patient #3's transfer was reviewed by hospital leadership. Interview revealed the hospital has altered processes. Interview revealed the ED has discontinued the practice of holding patients outside of the ED on the second floor. Interview revealed the hospital is looking at physically altering the ED to create a safe area to hold psychiatric patients. Interview revealed EMTALA protocols were reviewed. Interview revealed in EMTALA training was provided to the staff. Interview revealed "I learned a few things I did not know."

Interview on April 10, 2014 at 1605 with Licensed Practical Nurse (LPN) #1, revealed she works on the medical-surgical unit (second floor). Interview revealed she recalled Patient #3. Interview revealed she was the nurse who transferred the patient on 02/15/2014 at 2355 to Treatment Center A. Interview revealed the patient was considered an ED patient while on the floor. Interview revealed she received report from the day shift nurse at 1900. Interview revealed it was reported the (contracted MCM service) staff was in the house taking care of placement and that "all papers had been faxed, and the (contracted MCM service) staff would call back with more directions regarding placement." Interview revealed the (contracted MCM service) staff usually completed all the documents and paperwork. Interview revealed "the charge nurse did ask if I had everything for the transfer, and I replied that (contracted MCM service) had completed everything." Interview revealed "I have never transferred an ER patient before." Interview revealed "I was not familiar with the transfer forms." Interview revealed she received a telephone call and "(contracted MCM service) made me aware of placement." Interview revealed "the (contracted MCM service) staff member told me that there was no other paperwork needed and all I had to do was call dispatch and arrange for transport." Interview revealed the patient was going to be transferred to the (Treatment Center A). Interview revealed she called dispatch and made arrangements for transport. Interview revealed she made copies of the medical record to give to the sheriff's deputy. Interview revealed the on-duty ED physician (Physician C) did not assess the patient prior to his departure from the floor. Interview revealed (Physician C) did not complete a physician's certification for transfer form. Interview revealed "I was unaware the form needed to be completed." Interview revealed she did not call a report to the staff of Treatment Center A. Further interview revealed she recalled having a telephone conversation and receiving telephone orders from the ED physician (Physician C) on 02/15/2014 for Patient #3. Interview revealed she relayed to Physician C, that the patient complained of increased pain, was agitated, and wanted more pain medications, and that the patient's blood pressure was elevated. Interview revealed she did not give the physician any numerical values. Interview revealed she rechecked the patient's blood pressure at 2150 and the patient's blood pressure was 152/100. Interview revealed she did not check the patient's blood pressure at the time of his departure (2355). Interview revealed the patient was discharged alert and in no acute distress. Interview revealed the patient did not complain of headache, nausea, blurred vision, vomiting, or weakness. Interview revealed the patient left the hospital in the custody of the sheriff's deputy. Interview revealed she was familiar with EMTALA. Interview revealed she has received EMTALA training since 02/15/2014.

Interview on April 10, 2014 at 1035 with Sheriff Deputy #1 revealed he was a Deputy Sheriff for XYZ Sheriff's Department. Interview revealed he was the Deputy on-duty who transported Patient #3 from Hospital A to Treatment Center A and then to Hospital B on 02/15-16/2014. Interview revealed he went to the magistrate's office to pick up the IVC paperwork then came to Hospital A. Interview revealed the patient was located on the second floor of the hospital. Interview revealed the patient was ready to go when he arrived. Interview revealed he took the patient into custody and escorted him to the patrol car. Interview revealed he did not stop in the ED prior to departure. Interview revealed he transported the patient to (Treatment Center A name) located in Asheville, North Carolina. Interview revealed the transport was approximately 45 minutes. Interview revealed upon arrival at Treatment Center A the patient went through the interview process. Interview revealed the patient's blood pressure was noted to be elevated by the staff. Interview revealed the Treatment Center A staff would not accept the patient due to his elevated blood pressure. Interview revealed he was instructed to take the patient to the ED at Hospital B, in Asheville. Interview revealed he left Treatment Center A with Patient #3 and took the patient to Hospital B's ED. Interview revealed the patient was calm and cooperative during transport. Interview revealed the patient was agitated when he had to be taken to another hospital. Interview revealed the patient had no physical complaints and was ambulatory. Interview revealed he does not recall if he did or did not receive any paperwork from the nursing staff at Hospital A. Interview revealed he believed the (contracted MCM service) staff had already left and they usually have a packet ready for transport with the patient.

NC 569