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.

BRADFORD REGIONAL MEDICAL CENTER 116 INTERSTATE PARKWAY BRADFORD, PA 16701 Oct. 27, 2015
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on review of facility documentation and medical records (MR), and employee interviews (EMP), it was determined that the facility failed to ensure that all individuals presenting to the Emergency Department (ED) received examination and stabilizing treatment within the capabilities of the hospital for one of one patients (two visits) presenting to the Emergency Department (ED) with mental health symptoms (MR1[PT1] and MR2[PT1]).


Findings include:

Review, at approximately 12:45 PM on October 21, 2015, of the, "Agreement Between ... Bradford Regional Medical Center, ... and ... [OTH5] Emergency Medical Services Agreement," revealed, "... This agreement for services ("Agreement") is entered into with an effective date of January 1, 2010, by and between ... Bradford Regional Medical Center (collectively "Hospitals"), and ... [OTH5] (collectively "[OTH5]"). ... 2. [OTH5]'s Representations, Warranties and Covenants [OTH5] represents, warrants and covenants to Hospitals that each [OTH5] Provider: ... (i) will comply with written bylaws, rules and regulations, and policies of the applicable Hospital and its medical staff; ... 4. Individual [OTH5] Provider Responsibilities ... 4.2 Each [OTH5] Provider shall abide by the Bylaws, Rules and Regulations of the Medical Staff of applicable Hospital, and all applicable Hospital policies and procedures set forth in Hospital policy and procedure manuals. ... 4.4 Each [OTH5] Provider shall act in conformance with the applicable Hospital standard procedures in connection with their service for such Hospital, and in accordance with the ethics standards and requirements of [accrediting body], the American Medical Association, and all other Provider and governmental agencies that now or hereafter set standards for the practice of medicine generally and for the specific medical services that are the subject of this Agreement. 4.5 [OTH5] Providers designated or approved by [OTH5] shall act in conformance with all applicable local, State and Federal laws and regulations. This Agreement shall be interpreted in accordance with all such applicable laws and regulations. ... 5. Hospitals' Responsibilities ... 5.7 Both parties understand and agree to comply with all applicable laws involved. More specifically: (a) The parties shall comply with all applicable statutes, rules, regulations and standards of any and all governmental authorities and regulatory and accreditation bodies relating to physicians and hospitals, to the provision of Emergency Medicine Services, ... Schedule 1.2 Scope of Services ... (B) In fulfilling the duties and responsibilities hereunder, [OTH5] and [OTH5] Providers shall: ... (5) comply with and facilitate staff compliance with the Emergency Medical Treatment and Active Labor Act and regulations promulgated thereunder. ..."

Review of the Bradford Regional Medical Center Medical Staff Rules and Regulations, dated August 31, 2011, revealed, "ARTICLE I These Rules and Regulations are adopted by the Medical Executive Committee, and approved by the Board of Directors, to further define the general policies contained in the Medical Staff Bylaws, and to govern the discharge of professional services within the Hospital ... 1.1 DEFINITIONS ... "EMERGENCY" means a medical condition manifesting itself by acute care symptoms of sufficient severity (including severe pain) such as the absence of immediate medical attention could reasonably be expected to result in (a) 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, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. ... ARTICLE II ... 2.1.3 Assignment to Appropriate Service Areas Every effort will be made to assign patients to areas appropriate to their needs. Patients requiring emergency or critical care will be routed to the Emergency department for stabilization and transfer to the appropriate treatment area. ... 2.2 UNASSIGNED EMERGENCY PATIENTS The Emergency Medical Treatment and Active Labor Act (EMTALA) requires that for all patients who present to an Emergency Department, the Hospital must provide for an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. ... 2.2.2 Unassigned Call Service a. Unassigned Call Schedule: The Hospital is required to maintain a list of physicians and practitioners who are on call for duty after the initial examination to provide treatment necessary to stabilize an inpatient or outpatient with an emergency medical condition. Each Medical Staff Clinical Service Chair, or his/her designee, shall provide the Emergency Department and the Medical Staff Services Office with a list of physicians and practitioners who are scheduled to take emergency call for both consultations and admissions on a rotating basis. Emergency call shall be from 0800 to 0800 the following day. ... 2.2.4 Unassigned Patients Returning to the Hospital Unassigned patients who present to the Emergency Department will be referred to the practitioner taking unassigned call that day. ... 2.4 PATIENTS WHO ARE A DANGER TO THEMSELVES AND OTHERS The admitting practitioner is responsible for providing the Hospital with necessary information to assure the protection of the patient from self harm and to assure the protection of others. ... Regular hospital acute care admissions of suicidal patients will not be accepted except for those patients requiring medical or surgical stabilization. Once the patients' medical condition is stabilized, the patient will be evaluated and transferred to an appropriate outpatient or inpatient psychiatric facility or unit."

Review of the Bradford Regional Medical Center Policy and Procedure Manual, Policy #117.325, "EMTALA Guidelines for the Emergency Department," revised August 2012 revealed, "PURPOSE: To ensure that all patients are evaluated, stabilized and if necessary, transferred to another facility in a safe, efficient manner consistent with EMTALA guidelines. This policy is adapted form [sic.] EMTALA and applies to Health Care Providers, nursing staff and hospital. POLICY: ... 2) All patients shall receive a medical screening exam that includes providing all necessary testing and on call services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic. ... 4) Bradford Regional Medical Center will provide an on call physician specialty list which included [sic.] all specialties privileged at this facility. The on call list will be openly posted in the Emergency Department and a record of all on call lists shall be maintained for five (5) years. ... MEDICAL SCREENING EXAMS: 1) Medical Screening Exams should include at a minimum the following: ... e) Physical exam of affected systems and potentially affected systems. ... h) Notification and use of on call personnel to complete previously mentioned guidelines. i) Notification and use of on call physicians to diagnose and/or stabilize the patient as necessary. ... EMERGENCY MEDICAL CONDITIONS ... 2. Emergency medical conditions include: ... d) Psychiatric disturbances including severe depression, insomnia, suicide ideation or attempt, disassociative state inability to comprehend danger or care for self."

Review of the Bradford Regional Medical Center Policy and Procedure Manual, Policy #6440.002, "Admissions Voluntary and Involuntary," revised July 2015 revealed, "1) STATEMENT OF POLICY: a) It is the policy of Behavioral Health Services to admit patients according to the Mental Health Procedures of the State of Pennsylvania. ... 3) PROCEDURE ... Involuntary Admissions 1. Involuntary Commitments, Provisions 302, are the most frequent involuntary commitment. 2. The admission will be called to the psychiatric unit by the mental health delegate. He/she must also notify the attending psychiatrist of the admission. The nurse is responsible for notifying the emergency department."

Review, at approximately 9:50 AM on October 23, 2015, of Policy 670.329, "Care of the Psychiatric Patient in the Emergency Department," revised November 2011, revealed, "Purpose: To provide competent and accountable emergency psychiatric care to the patietn who present to the Emergency Department for a behavioral health evaluation. Policy Statement: Bradford Regional Medical Center Emergency Department will provide a consistent practice model for psychiatric patient care regardless of time of day with the collective goal for the provision of psychiatric care/substance abuse treatment to encompass the Institute of Medicines six Quality Aims of safe, effective, timely efficient, equitable and patient-centered care. Procedure: 1. Patients who present with psychiatric complaints will be triaged by a registered nurse using the Emergency Severity Index Triage System (ESI) to determine the acuity categorization and resources needed to ensure timely and appropriate evaluation and treatment and the patient's need for safety. (i.e. harm to self, harm to others). Triage according to BRMC Policy 6780.122. 2. Behavioral health staff will be notified immediately that the ED has a patient that needs to be evaluated. A mental status exam will be completed with documentation in the emergency department's electronic record. 3. A relevant psychiatric and focused medical assessment when indicated by triage or medical evaluation (a process by which medical etiology or the patient's symptoms is exclude [sic] and other illnesses and/or injuries in need of acute care are detected and treated), will be performed. Assessment findings which may indicate a patient has a medical illness of which a symptom-based evaluation is suggested include: a. Abnormal vital signs b. Abnormal physical exam relevant to clinical presentation c. Altered cognition relevant to clinical presentation. 4. The Behavioral Health Services staff, ED nurses, physicians, physician extenders and/or McKean County Mental Health delegates will engage in collaborative assessments completing psychiatric, nursing, social and medical assessments and evaluations. 5. Every effort will be made to place patients in a quiet room with a family member, if appropriate. 6. The primary nurse will do a nursing assdessment of systems utilizing the nursing process. 7. As part of the mental status exam, a suicide risk assessment will be performed by the primary nurse or mental health therapist with interventions provided if necessary and documentation of such in the electronic medical record. ... 11. The emergency room physician or physician extender ... will evaluate the patient. 12. Voluntary patients are required to sign voluntary admission form after full explanation by mental health counselor or RN. This most likely will occur in the Behavioral Health Unit but may be obtained in the ED by Behavioral Health Staff. 13. The primary nurse/mental health therapist will assess patient [sic] in terms of safety and determine the need for seclusion or restraints. 14. A seclusion room does not exist in the ED. ... Admission/Transfer to a Behavioral Health Unit every effort to ensure that patients requiring treatment are not boarded in the emergency department will be taken. 18. Consult the psychiatrist on call for disposition. 19. Complete proper documentation in the electronic medical record as outlin [sic] above. 20. ... Ensure medical clearance from ED physician, PA or NP. ... 22. Ensure application for involuntary admission completed and accompanies patient chart. 23. Ensure appropriate paperwork for admission/transfer completed in compliance wit [sic] EMTALA guidelines which includes noting in electronic record accepting facility and physician. ..."

1. Review of documentation from the Pennsylvania Department of Health, Division of Acute and Ambulatory Care and the Pennsylvania Department of Human Services revealed the facility to have a Psychiatric Unit with 28 licensed, inpatient beds for adult use (12 Psychiatric/16 Dual Diagnosis). Tour of the Emergency Department also revealed a room, identified by staff as the "Private Room", which contains a hand washing sink with electrical outlets covered and medical gases are encased and locked to prevent access by patients/visitors.


2. Review of the Bradford Regional Medical Center "ED (Unassigned Patient) Service Call- 8:00am - 8:00am," revealed a psychiatrist was available on-call to the ED on August 27, 2015.

3. Review of MR1 revealed the patient presented on August 27, 2015, with a complaint of "anxiety." Review of nursing documentation revealed, "Presentation: 08/27 08:55 Presenting complaint: HAS HX of PTSD, ANXIETY, AND SCHIZOPHRENIA. STATES ANXIETY HAS BEEN WORSE RECENTLY. ... Triage Assessment: 08:59 General: Appears uncomfortable, behavior is anxious. ... Suicide Screen: Patient admits to past attempts of suicide or self harm. ... reports hallucinations out of meds ... states [he/she] had a recent admission to an ICU following a suicide attempt. ... will not elaborate as to what method [he/she] used in an attempt to hurt [him/herself]. Reports auditory hallucinations for 'years' but worse lately. States the voices tell him to do things ... will not elaborate on what the voices are telling him to do. ..."

Review of documentation for MR1 authored by [EMP16], revealed, "Psych 10:25 [August 27, 2015] Ingestion of Foreign substance: Substance Ingested: alcohol, klonopin. Amount ingested: patient states 2 beers, 2 pills. Date ingested: August 26, 2015. Mental Status Exam: ... Anxiety: Anxiety level is noted to be severe. Precipitating factors are noted to be lack of support systems, interpersonal difficulty financial. History Patient has had previous suicide attempts. Past methods include hanging, shooting, motor vehicle. ..."

Review of Physician Documentation for MR1, authored by [EMP5] revealed, "09:47 [August 27, 2015] The patient presents to the emergency department with anxiety, psychosis, has experienced auditory hallucinations, voices are telling him to commit suicide, voices are telling patient to cause harm to someone else. Onset: The symptoms/episode began/occurred 2 week(s) ago. Past psychiatric history: Prior Diagnosis: schizophrenia, ... Associated signs and symptoms: Pertinent positives: anxiety, hallucinations, suicide ideation. Severity of symptoms: At their worst the symptoms were moderate in the emergency department the symptoms are unchanged. The patient has experienced similar experiences in the past, chronically. The patient has not recently seen a physician. Out of meds 2 weeks. ... ROS ... Psych: Positive for anxiety, auditory hallucinations, homicidal ideation. All other systems reviewed are negative. Exam: ... Constitutional: The patient appears in obvious distress, moderately distressed. 09:51 Psych: Behavior/mood is anxious ... Patient has no thoughts/intents to harm self or others. ... 10:57 ... I had a detailed discussion with the patient regarding the historical points, exam findings, and any diagnostic results supporting the discharge/admit diagnosis, lab results, the need for outpatient follow up a psychiatrist. ... discharged to Home/Self Care. Impression: Schizoaffective Disorder. -Condition is Stable. - Discharge Instructions: Schizoaffective Disorder. -Prescriptions for klonopin 1 gm Oral tablet- take 2 tablet(s) by oral route 3 times per day as needed; 30 tablet(s). ... -Follow up: Emergency Department; When: 2-3 days; Reason: If symptoms return. -Problem is an ongoing problem. -Symptoms have worsened." Review of MR1 revealed no documentation that the on-call psychiatrist was notified or, a consult obtained for the patient.

4. Review of nursing documentation for MR2, authored by [EMP8] revealed, "Presentation: 08/27 15:31 Presenting complaint: In the ED this morning with complaint of hearing voices, some of which were telling him to harm himself. Still experiencing same complaints. ... 15:45 Acuity: ESI 2 15:45 Method Of Arrival: Police Triage Assessment: 15:56 General: Appears distressed, Behavior is anxious. ... Screening: 15:41 ... Suicide Screen: Patient denies ever having thoughts that life is not worth living. Patient admits to past attempts of suicide or self harm. Patient is currently not thinking about ending their life. ... ***[Corrections: (The following items were deleted from the chart) 15:45 15:41 Suicide Screen: Patient denies ever having thoughts that life is not worth living. Patient denies ever attempting suicide or self harm. Patient is currently not thinking about ending their life. [EMP8]] *** Assessment: ... General: Appears distressed ... Behavior is anxious, Pt presents ambulatory with mental health delegate from home ... Pt was seen in ED this morning for same complaint, pt states [he/she] hears voices that tell [him/her] to hurt [him/herself] and others but denies any thoughts of acting on those thoughts. Pt requesting to be given 'something to help with my racing thoughts.' Pt stated 'If you plan on keeping me here for a long period of time you better just call security now, because I'll fight before I stay. I'd rather be in jail then stay in this place. That's a promise.' Pt reports taking three Klonopin of unknown dose after leaving ED this morning ad [sic.] 'passing out or something and falling in my garage.' Pt cannot remember what happened leading up to event, just waking up on the floor. Small amount of blood on forehead. ..."

5. Review of MR2 revealed the patient (PT1/MR1) returned to the Bradford Regional Medical Center a second time on August 27, 2015. The patient presented with police under "302" Involuntary Emergency Examination and Treatment paperwork. The documentation, dated August 27, 2015, revealed, "I believe that [PT1] is severely mentally disabled: (Check and complete all applicable for this patient) X (box was checked) the person has attempted suicide and there is reasonable probability of suicide unless adequate treatment is afforded under this act. For the purpose of this subsection, a clear and present danger may be demonstrated by the proof that the person has made threats to commit suicide and had committed acts which are in furtherance of the threat to commit suicide; ... Describe in detail the specific behavior within the last 30 days which supports your belief ... (Handwritten) [PT1] reports that [he/she] has been hearing voices telling [him/her] to hurt [him/herself]. [He/She] has had numerous suicide attempts in the past. [He/She] could not promise therapist that [he/she] would not harm [him/herself] again. [He/She] told caseworker [he/she] has been seeing black shadows of people harming people that [he/she] cares about. [He/She] has not been sleeping or eating. [He/She] has not been on medications." A box on the form was checked for a section stating, "The County administrator issue a warrant authorizing a policeman or someone representing the County Administrator to take the patient to a facility for examination and treatment." The petition was signed by [OTH1]. The County Representative checked and signed the section stating, "... I hereby order that [PT1] shall be taken to and examined at BRMC [Bradford Regional Medical Center] and if required, shall be admitted to a facility designated for treatment for a period of time not to exceed 120 hours ..."

6. Review of Physician Documentation authored by [EMP5] revealed, "08/27 16:04 ... presents to ER via Police with complaints of Psych Problem. ... The patient presents to the emergency department with paranoia, psychosis. Onset: The symptoms/episode began/occurred chronic. Past psychiatric history: Prior diagnosis: schizophrenia, Psychiatric medications include: Klonopin. Associated signs and symptoms: Pertinent positives; hallucinations, Pertinent negatives: homicidal ideation, substance abuse, suicide ideation. The patient has been seen at the Bradford Regional Medical Center Emergency Department today. ... ROS: ... Skin: Negative for injury ... Psych: Positive for anxiety, auditory hallucinations. Suicidal ideation. All other systems reviewed and are negative. Exam: ... Constitutional: This is a well developed, well nourished patient who is awake, alert, and in no acute distress. Head/Face: Normocephallic, no evidence of trauma. ... Psych: Behavior/mood is cooperative, anxious, Affect is calm, Oriented to person, place, time. Patient has no thoughts to harm self or others. Judgment /Insight is normal. Delusions/hallucinations ... Data reviewed: vital signs, nurses notes, lab test result(s). Counseling: I had a detailed discussion with the patient regarding the historical points, exam findings, and any diagnostic results supporting the discharge/admit diagnosis, lab results, the need for outpatient follow up a psychiatrist. ... Disposition: ... discharged to home/Self-Care. Impression: Schizoaffective Disorder. -Condition is Stable. - Discharge Instructions: Schizophrenia, Schizoaffective Disorder. -Prescriptions for Zyprexa 10 mg Oral Tablet- take 1 tablet by oral route once daily; 20 tablet. ... -Follow up: Private Physician; When: Next week; Reason: Continuance of care. -Problem is an ongoing problem. -Symptoms have worsened." Review of MR2 revealed no documentation that a Mental Health Therapist was notified, or evaluated the patient. There was further no documentation that the on-call psychiatrist was notified or consulted for the patient.

7. Review of (MR2) the 302 Involuntary Emergency Examination and Treatment section, "Part VI Physician Examination," contained in MR2, revealed, "... FINDINGS ... Seen by me this morning, states hearing voices to hurt self, but this is normal has no intention of hurting self or others wants to go to work." The form further revealed, "In my opinion (Check A or B) ... B (Checked) The patient is not in need of emergency involuntary treatment. He shall be returned to a place which he shall reasonably designate." The form was signed by [EMP5].

8. Review of MR2, and associated documentation, revealed no documentation that a Mental Health Therapist or the on-call psychiatrist had been notified and/or consulted for PT1.

9. When asked, at approximately 1:15 PM on October 21, 2015, if the case [MR1/MR2] was presented to the on-call psychiatrist, EMP4 stated, "It does not appear from the documentation that it was." During a subsequent interview with EMP4, on October 22, 2015, at approximately 11:30 AM surveyor asked if he/she provided Emergency Department staff EMTALA training or knew of specific EMTALA training for ED staff and [he/she] replied, "Haven't done anything yet since I just started [end of May 2015]."

10. On October 22, 2015, at 11:26 AM, when asked if there was any policy that required education on EMTALA, EMP13 stated, "We don't have a requirement."

11. During interview with EMP11 on October 22, 2015, at 1:00 PM surveyor asked him/her if he/she knew what EMTALA was and he/she replied, "I don't know what that is."

12. During interview with EMP17 on October 22, 2015, at 1:15 PM, surveyor asked him/her if he/she had EMTALA training, he/she replied, "Yearly basis through [OTH11] ... It is a mandatory process." Surveyor then asked him/her if EMTALA training was required for ED staff and he/she replied, "It [EMTALA] is a physician-driven process. ... It is a physician responsibility. ... I don't see where they [ED staff] would need the training."

13. During interview with EMP6 on October 22, 2015, at 2:00 PM surveyor asked when it is necessary to call psychiatry to stabilize a psychiatric patient he/she replied, "To be honest with you I am surprised this (PT1) didn't get a call [to psychiatry]."

14. When asked, at approximately 10:30 AM on October 23, 2015, if psychiatry was available on-call for PT1, why that consultation was not made, EMP5 stated, "I didn't feel a reason to call, because he/she did not need admitted ."

15. When asked, at approximately 10:40 AM on October 23, 2015, about the patient in question [PT1], EMP8 stated, "[He/She] was brought in by [OTH3]. [He/She] [OTH3] wanted to 302 [PT1] the second time [he/she] was there. I did a typical triage in triage room. Asked what brought [him/her] in today. I knew [he/she] was there earlier in the day. [He/She] denied suicidal ideations ... said [he/she] would rather be in jail than in the hospital ... denied thoughts of suicide but complained of racing thoughts and wouldn't elaborate on what the racing thoughts were. [EMP5] and I talked to [him/her] for a plan for racing thoughts versus keeping [him/her] here [admit to hospital]. [PT1] had discussed changing [his/her] meds but explained they [medications] wouldn't work overnight." When asked if he/she had reviewed the patient's 302 for MR2, EMP8 stated, "Not sure the 302 had been looked at, because [he/she] wanted to fight., not going to 302 this [patient] if [he/she] is going to fight." When asked if a psychiatric consult should be conducted, EMP8 stated, "If the decision to admit is made, then the doctor would call the psychiatrist." When further asked if he/she had EMTALA training EMP8 replied, "I don't believe so." When surveyor asked if he/she knew what EMTALA was he/she replied, "I have heard the term but couldn't tell you what it is."

16. When asked, at approximately 10:52 AM on October 27, 2015, about presenting with PT1 to the ED at BRMC on August 27, 2015, during the second visit, OTH2 stated, "They [ED staff] kind of went through everything from the morning [first visit]. They did say that psych was not going to see [him/her], because they saw [him/her] in the AM." When asked if anyone had said why the patietn would not be admitted , OTH2 stated, "They said because [he/she] was making threats. That was the reason." When asked if in his/her opinion the patient should have been admitted under the 302, OTH2 stated, "I think [he/she] should have been admitted ."
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based upon review of facility documents and medical records (MR), and employee interviews (EMP), it was determined that the facility failed to ensure an appropriate transfer for four of seven transfer medical records (MR18, MR19, MR22, MR23).

Findings:

Review, approximately 12:45 PM on October 21, 2015, of the, "Agreement Between ... , Bradford Regional Medical Center, ... and ... and [OTH5] Emergency Medical Services Agreement," revealed, "... This agreement for services ("Agreement") is entered into with an effective date of January 1, 2010, by and between ... Bradford Regional Medical Center (collectively "Hospitals"), and ... [OTH5] (collectively "[OTH5]"). ... 2. [OTH5]'s Representations, Warranties and Covenants [OTH5] represents, warrants and covenants to Hospitals that each [OTH5] Provider: ... (i) will comply with written bylaws, rules and regulations, and policies of the applicable Hospital and its medical staff; ... 4. Individual [OTH5] Provider Responsibilities ... 4.2 Each [OTH5] Provider shall abide by the Bylaws, Rules and Regulations of the Medical Staff of applicable Hospital, and all applicable Hospital policies and procedures set forth in Hospital policy and procedure manuals. ... 4.4 Each [OTH5] Provider shall act in conformance with the applicable Hospital standard procedures in connection with their service for such Hospital, and in accordance with the ethics standards and requirements of [accrediting body], the American Medical Association, and all other Provider and governmental agencies that now or hereafter set standards for the practice of medicine generally and for the specific medical services that are the subject of this Agreement. 4.5 [OTH5] Providers designated or approved by [OTH5] shall act in conformance with all applicable local, State and Federal laws and regulations. This Agreement shall be interpreted in accordance with all such applicable laws and regulations. ... 5. Hospitals' Responsibilities ... 5.7 Both parties understand and agree to comply with all applicable laws involved. More specifically: (a) The parties shall comply with all applicable statutes, rules, regulations and standards of any and all governmental authorities and regulatory and accreditation bodies relating to physicians and hospitals, to the provision of Emergency Medicine Services, ... Schedule 1.2 Scope of Services ... (B) In fulfilling the duties and responsibilities hereunder, [OTH5] and [OTH5] Providers shall: ... (5) comply with and facilitate staff compliance with the Emergency Medical Treatment and Active Labor Act and regulations promulgated thereunder. ..."

Review, at approximately 9:15 AM on October 23, 2015, of Policy 117.004, "Treat and Transfer from the Emergency Department," revised August 2012, revealed, "... Policy: It is the policy of Bradford Regional Medical Center to ensure safe and quality patient care in times of high census. Purpose: ... 6. The Emergency Department will continue to triage and treat all incoming ESI [Emergency Severity Index] Level 1 through 5 patients. Both stabilized and unstable patients will be transferred in accordance with EMTALA guidelines. ..."

Review, at approximately 9:18 AM on October 23, 2015, of Policy 6000.066, "Transfer of a Patient (Inpatient, to Extended Care Facility, to Another Facility, Ground, Air, ACLS, MICU)," revised February 2015, revealed, "... C. Transfer to Another Facility Policy: All patient transfers from Bradford Regional Medical Center to another acute care facility due to an emergency are considered discharges from Bradford Regional Medical Center and must be ordered by a physician with provisions of type (MICU, ACLS, BCLS, or AIR). Purpose: To ensure that all patients within Bradford Regional Medical Center are safely transferred to the most appropriate environment conducive to meeting their needs and level of care require also to enable the continuation of the same level and quality of care in transit as was initiated prior to transfer. ... Procedure: ... ER makes arrangements for patients transferred directly from the ER. Transfer arrangements are made with an appropriate service, according to the level of care necessary. Patients being transferred will be given a choice of local service providers. ... 5. The Physician and/or the Nursing staff must complete the following forms prior to transfer: A. Medical necessity B. Consent for transfer C. "Provider choice" form if ground transport ... 7. Nursing personnel will notify the receiving facility of the transfer and expected time of arrival. 8. The RN sending the patient is responsible for providing a written and verbal report to the receiving facility. This report will contain all pertinent information regarding the patients past and present health status, testing, medications, level of care required and MDRO status/isolation. ... 13. It is the transferring physician's responsibility, to determine the level of care necessary for patient transport. ... 15. Ensure full report has been given to MD and/or RN at receiving hospital by telephone. ..."

Review, at approximately 9:50 AM on October 23, 2015, of Policy 670.329, "Care of the Psychiatric Patient in the Emergency Department," revised November 2011, revealed, "... 23. Ensure appropriate paperwork for admission/transfer completed in compliance wit [sic] EMTALA guidelines ... 26. Report will be called to receiving unit or facility. ..."

1. Review, at approximately 9:30 AM on October 23, 2015, of MR18 revealed that the patient was accepted at another facility as a psychiatric transfer. Review revealed an incomplete, "Acute Care Transfer Form."

Review of the patient's, "Acute Care Transfer Form," revealed that Section 8, "Consent For Transfer/Refusal of Offered Services," did not have the patient's name indicated, and did not have an appropriate category selected, as to consent or refusal. Further review of Section 9, entitled, "Transfer," did not reveal documentation that the facility report was called, the contact person, and the date or time of report.

2. Review, at approximately 9:45 AM on October 23, 2015, of MR19 revealed that the patient was accepted at another facility as a transfer. Review revealed an incomplete, "Acute Care Transfer Form."

Review of the patient's, "Acute Care Transfer Form," revealed no documentation of the person contacted at the receiving facility for report, nor the date/time of the report under Section 9, "Transfer."

3. Review, at approximately 10:35 AM on October 23, 2015, of MR23 revealed that the patient was accepted at another facility as a psychiatric transfer. Review revealed an incomplete, "Acute Care Transfer Form."

Review of the patient's, "Acute Care Transfer Form," revealed that Sections 1-3 were not completed. The Sections mentioned include: Medical Screening Examination, Stabilization Status, and Reason for Transfer.

When asked, at the time of record review, who is responsible to complete Sections 1-3 of the, "Acute Care Transfer Form," EMP4 stated, "That section is the physician's responsibility."

When asked, at the time of record review, if report was called to the receiving facility, and if so, who and at what time did report take place, EMP4 stated, "I cannot tell you that for sure. [He/She][Nurse] did not fill in that section [of the "Acute Care Transfer Form"]."

4. Review, at approximately 10:55 AM on October 23, 2015, of MR22 revealed that the patient was accepted as a psychiatric transfer to another facility. Review did not reveal a completed, "Acute Care Transfer Form," per facility policy.

Review, at approximately 10:00 AM on October 23, 2015, of a blank copy of the, "Acute Care Transfer Form," revealed the following information to be contained on this form: Medical Screening Examination, Medical Condition Requiring Transfer, Stabilization Status, Reason for Transfer, Risks Versus Benefits [of transfer], Transfer Order, Mode of Transportation, Physician Signature, Consent for Transfer/Refusal of Offered Services, Transfer [report to receiving facility], Patients Medical Record [documentation of what was sent to receiving facility], and Vital Signs at the time of Transfer.

EMP4, present, at the time of above review, confirmed the above findings, stating, "[EMP2] ... even looked in the legal record. ... If it [Acute Care Transfer Form] was done, I don't have any proof. ..."