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.

SONORA BEHAVIORAL HEALTH HOSPITAL 6050 NORTH CORONA ROAD TUCSON, AZ Sept. 18, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
[The provider agrees,] in the case of a hospital as defined in 489.24(b), to comply with 489.24.

This STANDARD is not met based on direct observation of posted/not posted EMTALA signage, review of emergency services patient log, medical records, hospital documents, hospital policies and procedures, including EMTALA policy, By-Laws, Rules, and Regulations of the Medical Staff and interviews, it was determined that the hospital failed to enforce policies and procedures that comply with the requirements of 42 CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases by failing to:

489.20(q) Tag A2402

a) post an EMTALA sign in the walk-in entrance which included all required elements; post an EMTALA sign in Spanish (community is 36% Hispanic according to the US Census Bureau);

b) post EMTALA signage in both emergency entrances;

489.20(r)(3) Tag A2405

a) record on the emergency room Log each individual who came to the emergency department seeking assistance in 2 of 16 patients who were unscheduled, unexpected "walk-ins," and who were subsequently transferred to an acute care hospital Emergency Department (Patient #'s 16 and 17);

489.24(a) Tag 2406

a) ensure that 17 of 18 patients who were transferred to another medical facility were provided an appropriate Medical Screening Examination (MSE) within its capabilities (Patient #'s 1, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, and 23);


489.24(d)(1-3) Tag A2407

a) provide stabilizing treatment, determine stability for transfer, or document the benefit of transfer to a different level of care for evaluation, stabilization and/or treatment for 15 of 18 patients who were transferred to outside medical facilities (Pt #s 1, 22, 11, 19, 20, 21, 23, 7, 8, 9, 10, 12, 13, 16 and 17); and

489.24.(e)(1)-(2) Tag A2409

a) conduct appropriate transfers for 18 of 18 patients who presented to the hospital for assistance with a medical/psychiatric condition.

The cumulative effect of these deficient practices resulted in the hospital's failure to be in compliance with EMTLA requirements.
VIOLATION: POSTING OF SIGNS Tag No: A2402
Based on policy and procedure review, document review, US Census Bureau "Quick Facts," direct observation, and interview, it was determined that the provider failed to post signage in the required areas, specifying the rights of patients who present with emergency medical conditions.

Findings include:

The "EMTALA-Screening, Stabilization and transfer of Individuals with Emergency Medical/Psychiatric Conditions" policy, revised 03-01-14, revealed: "...PURPOSE: To assure that those (corporation) facilities licensed to operate hospital services are in compliance with the provisions of the Emergency medical treatment and Active Labor Act (EMTALA) and subsequent amendments...POSTING REQUIREMENTS Each (corporation) Medicare/Medicaid participating hospital shall post in its intake department, waiting area, reception area, and any other area in which an emergent individual might be present, a sign in English, and in any other language prevalent in the community, stating the facility participates in the Medicare/Medicaid program and specifying the rights of individuals under EMTALA for a medical screening exam, stabilizing treatment, and appropriate transfer regardless of ability to pay. The wording of the sign(s) must be clear and in simple terms and language that are understandable by the population served by the hospital. Signs must be reasonably visible and readable from 20 feet away from where the individual would be located...."

A document provided by hospital personnel, dated 06/16/2014, and described as "Power Point Training," revealed: "...What you can do to avoid an EMTALA violation...Post required EMTALA signs...."

"Pima County Quick Facts from the US Census Bureau," posted on the Census Bureau website, revealed that for Pima County, Arizona, the county in which Tucson is geographically located, the population is 36.1 % "Hispanic or Latino" as of 2014.

Direct observation conducted on 09-16-15 at 3:50 P.M., of the main entrance to the hospital, where walk-in patients presented, revealed an EMTALA sign approximately 26 feet from the entrance door. The sign was located on a far wall of the rectangular-shaped waiting room/lobby, not adjacent to the receptionist window to which patients present. The sign was written in English only. The sign did not indicate if the hospital was a Critical Access Hospital (CAH), or if it participated in the Medicaid program under a State plan.

Direct observation conducted on 09-16-15 at 3:57 P.M., revealed a door (Door #1) to which ambulances arrive which goes into a sallyport (a secure, controlled entryway) which was the entrance to adult units of the hospital. There was no EMTALA signage in the sallyport, where patients arrive by ambulance until taken to a hospital unit.

Direct observation conducted on 09-16-15 at 4:00 P.M., revealed a door (Door #2) to which ambulances arrive which goes into a sallyport which was the entrance to an adult unit and a youth unit. There was no EMTALA signage in the sallyport, where patients arrive by ambulance until taken to a hospital unit.

Direct observation conducted on 09-16-15 of the sign posted in the waiting room/lobby to which walk-in patients present, revealed: "...IT'S THE LAW IF YOU HAVE A MEDICAL EMERGENCY OR ARE IN LABOR, YOU HAVE THE RIGHT TO RECEIVE, within the capabilities of this hospital's staff and facilities: An appropriate medical SCREENING EXAMINATION Necessary STABILIZING TREATMENT (including treatment for an unborn child), and, if necessary, An appropriate TRANSFER to another facility Even if YOU CANNOT PAY or DO NOT HAVE MEDICAL INSURANCE..." There was no corresponding sign posted in Spanish. There was no verbiage which indicated that the hospital participated in the Medicaid program under a State plan approved under Title XIX. The surveyor, with corrective lenses, was unable to read the signage at an approximate distance of 20 feet.

Direct observation, conducted on 09-17-15, revealed two entrances to the hospital to which ambulances arrived with patients. Door #1 revealed an entrance into a sallyport to which Emergency Medical Services (EMS) entered the hospital with the patient. There was no signage inside the sallyport related to EMTALA. Door #2 revealed an entrance into another sallyport to which Emergency Medical Services (EMS) entered the hospital with the patient. There was no signage inside the sallyport related to EMTALA.

The Director of Risk Management acknowledged, during interview conducted on 09-17-15, that there was no EMTALA signage at the entrances to which emergent patients presented by ambulance.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on review of hospital documents, the hospital "EMTALA Log", and interview, it was determined that the hospital failed to record on the log, each individual who comes to the emergency department seeking assistance for 2 of 16 patients who were unscheduled, unexpected "walk-ins" and were transferred to an acute medical center Emergency Department (Pt #'s 16 and 17).

Findings include:

The Director of the Assessment and Referral Department (A and R) provided a folder containing forms titled EMTALA/Transfer Record. The forms contained the heading: "To Be Utilized For All Patient Transfers Emergency and Non Emergency To Be Completed by Qualified Medical Personnel At Sending Facility." The bottom of the forms contained instructions: "Original to Medical Record-Make Copies For Receiving Facility And Patient."

The folder contained a form with Pt # 16's name written at the bottom right corner. This form contained documentation: "pt exp sz (patient experienced seizure) type activity vs (versus) syncope" written on the line designated for: "...The nature of the emergency/medical condition..." The form also contained documentation that Pt # 16 was transferred by ambulance to (Name of Acute Medical Center) on 8/17/15.

The folder contained a form with Pt # 17's name written at the bottom right corner. This form contained documentation: "elevated vitals, bilat (bilateral) lower leg swelling" written on the line designated for: "...The nature of the emergency/medical condition..." The form also contained documentation that Pt # 17 was transferred by ambulance to (Name of Acute Medical Center) on 8/13/15.

Review of the hospital's EMTALA Logs for dates 8/17/15 and 8/13/15, revealed that the Logs did not contain the names of Pt # s 16 and 17.

The Director of A and R confirmed, during an interview conducted on 9/16/2015, that A and R staff are required to record the names of all patients seeking assistance on the EMTALA Log. She confirmed that Pt # s 16 and 17 were both seen by an RN working in A and R and were transferred from the hospital to an acute medical center and were not "logged in" as required.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on review of hospital policy/procedure, interviews, hospital documents and medical records, it was determined that the hospital failed to provide an appropriate medical screening examination within it's capability as evidenced by:

1. failing to provide a completed medical screening examination for 17 of 18 patients who were transferred to outside medical facilities (Pt #s 1, 22, 11, 19, 20, 21, 23, 7, 12, 13, 14, 15, 18, 9, 10, 16 and 17); and

2. failing to require that the portions of medical screening examinations recorded for 5 of 5 patients, who were transferred to outside hospitals, be conducted by individuals determined to be qualified by hospital bylaws, rules and regulations or policy, as required by hospital policy (Pt #s 8, 9, 10, 16, 17 and 18).


Findings include:

1. Review of hospital policy titled EMTALA-Screening, Stabilization and Transfer of Individuals with Emergency Medical/Psychiatric Conditions revealed: "...Emergency Medical Condition-A medical condition manifesting itself by acute symptoms of sufficient severity...such that the absence of immediate medical attention could reasonably be expected to result in: a) Placing the health of the individual in serious jeopardy; b)Serious impairment to bodily function; or c)Serious dysfunction to any part of the body...an individual expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or others, would be considered to have an emergency medical condition...Intoxicated individuals may meet the definition of an emergency medical condition...Medical Screening Exam-A process required to reach, with reasonable clinical confidence, the point at which it can be determined that a medical emergency does or does not exist...For individuals with psychiatric symptoms, the medical screening exam should include an assessment of suicidal or homicidal attempts or risks, disorientation, assaultive behavior that indicates danger to self or others...The medical screening exam and stabilizing treatment must be provided to all patients...and must include the full complement of tests and ancillary services available to the hospital, if called for by the patient's condition...Transfer - The movement, including discharge-of an individual outside of the hospital facilities, at the direction of any person employed, affiliated or associated with the hospital, but NOT including: Movement of a stable individual to another hospital if it is the intent and understanding of both facilities that the individual is going to the second facility only for tests, the individual will not remain overnight, and the individual will return to the facility...Departure of individuals from the facility without permission...Movement of an individual who has been declared dead...All individuals who come to the Hospital's dedicated emergency department for assistance with a medical condition, or come on hospital property for assistance with an emergency medical condition, will receive a medical screening exam and appropriate stabilizing treatment performed by a Qualified Medical Person prior to any decisions regarding admission, discharge, transfer, or referral...."

The Director of the Assessment and Referral Department (A&R) stated, during an interview conducted on 9/16/2015, that the medical screening examination is composed of two parts: a screening for emergency medical conditions, completed by the RN and a screening for emergency psychiatric conditions, completed by the A and R Evaluator. The RN documents findings on a form titled Medical History Part-I-Non Direct Patient. The Evaluator documents findings on a form titled Psychiatric Screening Assessment Part 2 Non-Direct Patient, for the patient who is being transferred to another facility. If the patient requires admission, the Evaluator completes a form titled A and R Assessment. She confirmed that a medical screening examination is required for any patient transferred to another medical facility.

Pt # 1

The hospital EMTALA Log, dated 4/18/15, contained documentation that Pt # 1 arrived via Emergency Medical Services (EMS) for "SI (Suicidal Ideation)". He was "...sent back to (Name of Crisis Stabilization Unit)-pt had right hand in cast." The mode of departure was not documented.

The hospital was unable to provide any documentation of a medical screening examination for Pt # 1.

Review of Pt # 1's medical record from the sending facility revealed that he had arrived at the facility on 4/15/15, voluntarily, accompanied by local police. He presented with suicidal ideation and depression. A physician documented that Pt # 1 was suicidal and psychotic, with hallucinations, delusions, poor reality testing and lacking the insight and judgment needed to care for himself independently or "...respond to others appropriately outside this level of care..." A physician documented, on 4/16/15: "...Plan: transfer to Level 1 facility (psychiatric hospital) for stabilization...."

On 4/17/2015, a physician at the sending facility documented Pt # 1's Primary Diagnosis: "...Schizophrenic disorders: Paranoid type: chronic with acute exacerbation...." The physician documented that the patient "...remains psychotic with hallucinations, delusions, and/or poor reality testing and lacks the insight and judgment needed to care for him/herself independently or respond to others appropriately outside this level of care...."

On 4/17/2015, staff at the sending facility documented that Pt # 1 was going to a Level 1 facility.

On 4/18/2015, at 12:15 AM an RN documented: " Pt D/C (discharged ) to (Name of Hospital) for continuation of his psychiatric care. Report given to...RN and DOC to DOC done. Pt safe at time of transfer. In good behavioral control...."

On 4/18/2015, at 1:25 AM, an RN at the sending facility documented: "...Client returned from (Name of Hospital) after staff refused to accept client for treatment due to clients (sic) cast on left arm...Presentation: SI (Suicidal Ideation)...."

On 4/18/2015, at 0600, staff documented "...no Level 1 beds available in the community at this time...."

On 4/18/2015, at 1040, a physician documented: "...He returned to the (Name of Crisis Stabilization Unit) after (Name of Hospital) reneged on the admission authorization. He remains inappropriate for this discharge outpatient care...Admit to the [STIU (Short Term Inpatient Unit)] when a bed is available...."

On 4/18/2015, at 1503, a physician documented: "...Discharge Plan...transfer to Level 1...."

On 9/14/2015, the Director of Risk Management at the hospital confirmed that Pt # 1 had been accepted for admission and arrived at the hospital via ambulance. She stated that the EMS brought Pt # 1 into the "sallyport/breezeway" area; that the RN and A and R staff member saw that Pt # 1 had a "hard cast" on his right hand, and had received the injury due to previous assaultive behavior. She stated that the facility had not been informed of the patient's cast, and that casts are considered on a "case by case" basis. She confirmed that the patient was returned to the sending facility via the same ambulance that had transported him to the hospital. She confirmed that the hospital did not have any documentation of Pt # 1's arrival. She confirmed that hospital staff did not complete a medical screening examination, including assessment of Pt # 1's psychiatric condition, nor did they complete a certificate of transfer as required.

On 9/14/2015, the Director of the A and R Department confirmed that Pt # 1 had been accepted for admission and had arrived at the "sallyport/breezeway" via ambulance. She stated that the staff returned the patient to the sending facility due to the "hard cast". She stated her belief that Pt # 1 was not considered a patient of the hospital, or the responsibility of the hospital until he was inside the locked double-doors of the hospital inpatient unit. She confirmed that the hospital had no documentation of Pt # 1's arrival, assessment of his condition, or certification of transfer back to the sending facility.

On 9/16/2015, Physician # 3 confirmed that he was the on-call physician on the date and at the time that Pt # 1 was received by the hospital for admission. He did not recall whether he was contacted by hospital staff after the patient arrived. He was aware that the patient required an assessment prior to being transferred from the hospital elsewhere, and that he assumed that the RN would have completed an assessment. He was aware that a "hard cast" is "exclusionary criteria", but that his ordinary practice is to accept a patient, and determine whether the patient requires treatment elsewhere later. He confirmed that the sending facility provides a lower level of care than the hospital.

The hospital accepted Pt # 1 for admission as a transfer from the sending facility. The hospital did not have documentation of the "Nurse to Nurse" communication, the "DOC to DOC" between the sending facility RN and the hospital RN, or between the physicians. The hospital had not considered Pt # 1 a patient of their facility until he was actually admitted and present on their inpatient unit. Staff did not complete a Medical Screening Examination or certification of transfer. Staff instructed the EMS to return Pt # 1 to a lower level of care after a physician had determined that he required acute psychiatric hospitalization .

Pt # 22

The hospital EMTALA Log, dated 7/11/15, contained documentation that Pt # 22 arrived via EMS for "SA (Suicide Attempt) AH (Auditory Hallucinations)." He was "...sent to (Name of Acute Medical Hospital) for med clearance...(Admit canceled)..." The mode of departure was not documented.

Review of hospital document titled (Name of Hospital) Inquiry Call Worksheet revealed: "...Presenting Problem...Pt cut length-wise and did cut a vein in upper arm. Pt reports he has AH that are 'attacking me' and tell him to cut himself or cut his friends...Patient not admitted due to obvious, gross infx (infection) of LUE (Left Upper Extremity), forearm, multiple areas of pus, reddened, swollen and hot to touch. Assessment did match that reported by (Name of Sending Hospital) report (verbal) from RN...."

The hospital was unable to provide any documentation of a medical screening examination for Pt # 22.

Review of the sending hospital's ED record of Pt # 22 revealed: "...Psychiatric Review: He is obviously in severe psychiatric distress...Severe psychiatric illness, hypertension...brisk bleeding...This is obviously a very disturbed gentleman who will need psychiatric help...Diagnoses:...Self-mutilation, self-injury...a 50 cm single layer closure wound of the left forearm, suture of the wound from the left forearm...."

The Director of the A and R Department confirmed, during interview conducted on 9/18/15, that Pt # 22 had been accepted for admission and arrived at the hospital via ambulance. She confirmed that the hospital did not complete a medical screening examination of Pt # 22, and canceled his admission, sending him to an acute medical hospital without a certification of transfer.

Pt # 11

The hospital EMTALA Log, dated 4/8/15, contained documentation that Pt # 11 arrived by Privately Owned Vehicle (POV) for "Detox". He was "sent to (Name of Acute Medical Hospital) for medical clearance." The hospital was unable to provide documentation of a medical screening examination. The patient departed by POV.

Review of the receiving hospital's ED record for Pt # 11 revealed: "...the patient presents with alcohol intoxication...Systolic Blood Pressure 155 mmHg HI...Diastolic Blood Pressure 140 mmHg>HHI...ETOH Rawval...258.9 mg/dL HI...Diagnosis...alcohol intoxication...elevated blood pressure...Behavioral Health Risk Assessment...Disposition: vol inptn (voluntary inpatient) @ Level 1...."

Pt # 19

The hospital EMTALA Log, dated 5/1/15, contained documentation that Pt # 19 arrived by POV for "Psych". She was "referred to (Name of Acute Medical Hospital) re: vitals". Her mode of departure was not documented.

Review of the receiving hospital's ED record for Pt # 19 revealed: "...Triage Note: pt with hx (history) of anxiety and depression, verbalizes si (suicidal ideation)...Mode of Arrival: Walking...." Vital signs recorded during the visit included: Systolic BP: 100 and Diastolic BP: 70. Her Pulse was 77. An MD documented diagnosis: "Suicidal Ideation...Depression...Anxiety...." The behavioral health evaluator recommended admission to a level 1 facility.

Pt # 20

The hospital EMTALA Log, dated 6/29/15, contained documentation that Pt # 20 arrived by POV for "detox". She was "sent to (Name of Acute Medical Hospital) ER". Her mode of departure was not documented.

Review of the receiving hospital's ED record for Pt # 20 revealed: Pt # 20 arrived by ambulance. "...pt presented to (Name of Hospital) for detox and came from there to (Name of Receiving Acute Medical Hospital) by ambulance for medical clearance...The patient presents with alcohol intoxication...." She remained in the ED for 8 hours.

Pt # 21

The hospital EMTALA Log, dated 7/12/15, contained documentation that Pt # 21 arrived by POV for "psychosis?". She was "sent out for med clearance per (NP # 1)." Her mode of departure was not documented.

Review of the receiving hospital's ED record for Pt # 21 revealed: "...Patient presents to emergency department with auditory hallucinations. She states she has a history of psychiatric disorders, including schizophrenia. she (sic)states that her auditory hallucinations increased in severity last night. she (sic) states that the voices are telling her to kill her doctor and her nurse...The pt has remained in this facility due to lack of available beds in the community...Facilitate transfer to inpt mental health treatment...."

The Director of Assessment and Referral (A and R) confirmed during an interview conducted on 9/18/2014, that Pt #s 11, 19, 20 and 21 arrived at the hospital's A and R Department seeking assistance. They were all unscheduled, unexpected visits. All four patients were transferred to an acute medical hospital ED. She confirmed that she was unable to provide evidence that these 4 patients received medical screening examinations prior to transfer.

Pt # 23

The hospital EMTALA Log, dated 7/1/15, contained documentation that Pt # 23 arrived by POV for "ETOH (alcohol) Dep (Dependence)". He was "sent to (Name of Acute Medical Hospital) for med (medical) clearance". His mode of departure was POV.

Review of hospital document titled (Name of Hospital) Inquiry Call Worksheet revealed: "...Presenting Problem...Cocaine and ETOH-2 pints Daily x 1 month...7/01/15-@2000 RN...sent client to (Name of Acute Medical Hospital) for clearance. Pt had been drinking and since we are unable to get a BAL (Blood Alcohol Level) (RN) felt client need (sic) to be cleared. (RN) spoke w/Mother who was going to take client to (Name of Acute Medical Hospital) & return to (Name of Hospital)...@ 2208...called the main ER and they did not have the client and spoke w/... and they had no clients...@ 2211...called pt and Mother to find out what happened and both phone went to voice msg...."

The Director of A and R stated during interview conducted on 9/16/15, that the Inquiry Call Worksheet is completed by A and R staff for every patient who enters the A and R Department. The Sheet is completed when a call is received, prior to the patient's arrival, and/or when a patient arrives without a prior telephone call. Pt # 23 arrived at the hospital's A and R Department seeking assistance. His visit was unscheduled and unexpected. The Director of A and R confirmed that an RN sent Pt # 23, via POV, to (Name of Acute Medical Hospital) ED without completing a medical screening examination.

Pt # 7

The hospital EMTALA Log, dated 6/9/15, contained documentation that Pt # 7 arrived by POV for "Depression Opiate Dep (Dependence)". He was "referred to get medically cleared." His mode of departure was not documented.

Review of hospital document titled (Name of Hospital) Inquiry Call Worksheet revealed: "...Presenting Problem...(minor) male presented for depression & substance abuse. Pt refused to get out of dad's vehicle & enter the building. Pt's father reported that pt had been using cocaine & other unknown substances. Pt's father reported that pt was slurring his words & unable to stay awake. This writer suggested that pt get medically cleared...."

The Director of A and R confirmed during interview conducted on 9/16/15, that Pt # 7, a minor, arrived at the hospital and his father was seeking assistance on Pt # 7's behalf. His visit was unscheduled and unexpected. She stated that she believed that the hospital had no responsibility to provide service to an individual who refuses to come inside the building. She confirmed that an A and R Evaluator directed Pt # 7's father to take him to another facility without completing a medical screening examination.

Pt # 12

The hospital EMTALA Log, dated 6/18/15, contained documentation that Pt # 12 arrived by POV for "Detox". He was "sent to (Name of Acute Medical Hospital) for med (medical) clearance". His mode of departure was Emergency Medical Services (EMS). A transfer form contained documentation that Pt # 12's "...emergency/medical condition is: "...Chest pain, elevated vitals..." The transfer form contained documentation of transfer by ambulance with Paramedic.

Review of the receiving hospital's ED record for Pt # 12 revealed: "...hyperglygemia at 400 blood...He does have a cardiac history...chest pain he had today...related...to...not using his heroin...The patient presents with chest pain...elevated blood pressure...."

Pt # 13

The hospital EMTALA Log, dated 5/14/15, contained documentation that Pt # 13 arrived by POV for "SI (Suicidal Ideation)." She was "referred to (Name of Acute Medical Hospital) Med/Psych ". Her mode of departure was EMS. A transfer form contained documentation that Pt # 13's "...emergency/medical condition is: SI w/plan, unable to accommodate (sic) medical need at (Name of Hospital)...."

Pt # 14

The hospital EMTALA Log, dated 7/29/15, contained documentation that Pt # 14 arrived by POV for "Detox". He was "sent to (Name of Acute Medical Hospital)". His mode of departure was not documented on the Log. A transfer form contained documentation that Pt # 14's "...emergency/medical condition is: "...elevated vitals, high BAL (Blood Alcohol Level) cardiac hx (history)..." The transfer form contained documentation of transfer by ambulance.

Review of the receiving hospital's ED record for Pt # 14 revealed: "...Patient presents with alcohol intoxication...He self presented to (Name of Hospital)...he needs medical clearance...he has no medical complaints...ED pulse rate...124 bpm (beats per minute)...Systolic Blood Pressure...142 mmHg HI...Diastolic Blood Pressure...108 mmHg HI...ETOH Raw/Val...303.7 mg/dL HI...."

Pt # 15

The hospital EMTALA Log, dated 8/25/15, contained documentation that Pt # 15 arrived by POV for "ETOH Detox". He was "sent to ER for medical clearance." His mode of departure was not documented on the Log. A transfer form contained documentation that Pt # 15's "...emergency/medical condition is: BAL 0.320, intoxication..." The transfer form contained documentation of transfer in "Mother's private car."

Review of the receiving hospital's ED record for Pt # 15 revealed: "...he is clearly intoxicated and his blood alcohol level 329 mg percent...Behavioral Health Risk Assessment...History of 25 stays at detox. History of DT (Delirium Tremens) and seizures with withdrawals...patient reports chills, tremors...."

He remained in the ED for approximately 18 hours.

Pt # 18

The hospital EMTALA Log, dated 4/21/15, contained documentation that Pt # 18 arrived by POV for "Detox". She was "sent to ER..." Her mode of departure was not documented on the Log. A transfer form contained documentation that Pt # 18's "...emergency/medical condition is: BAL 0.419, elevated vitals..." The transfer form contained documentation of transfer by "...POV w/family...."

The Director of A and R confirmed during an interview conducted on 9/18/2014, that Pt #s 12, 13, 14, 15 and 18 arrived at the hospital's A and R Department seeking assistance. They were all unscheduled, unexpected visits. All five patients were transferred to an acute medical hospital ED. She confirmed that she was unable to provide evidence that these 5 patients received medical screening examinations prior to transfer.

Pt # 9

The hospital EMTALA Log, dated 8/20/15, contained documentation that Pt # 9 arrived by "agency" for "Medical". She was "sent to medical." Her mode of departure was not documented on the Log. An RN completed a Medical History Part I form. An Evaluator did not complete a Psychiatric Screening Assessment Part 2. The RN documented that Pt # 9 refused transfer to (Name of Acute Medical Hospital) and ambulance transport. The RN documented that the "agency representative" who accompanied the patient arranged for transport via "HandiCar" to (Name of Acute Medical Hospital) for "medical assessment."

The Director of A and R confirmed that Pt # 9 did not have a complete Medical Screening Examination prior to transfer to an acute medical hospital.

Pt # 10

The hospital EMTALA Log, dated 3/24/15, contained documentation that Pt # 10 arrived by POV for "anxiety". She was "referred to ER chest pain." Her mode of departure was not documented on the Log. An RN completed a Medical History Part I form. An Evaluator did not complete a Psychiatric Screening Assessment Part 2. The RN documented: "...Pt rated chest pain 9.5/10. (Physician # 3) requested that pt get medically cleared...."

The Director of A and R confirmed that Pt # 10 did not have a complete Medical Screening Examination prior to transfer to the ER.

Pt # 16

The hospital EMTALA Log, did not contain documentation of Pt # 16's arrival or departure. An RN completed a Medical History Part I form and a portion of a transfer form, dated 8/17/15. The transfer form contained documentation: "...nature of the emergency/medical condition is: Pt exp (experienced) sz (seizure) type activity vs (versus) syncope...Mode of Transfer...Ambulance with Paramedic...Name of Receiving Facility: (Name of Acute Medical Hospital)..."An Evaluator did not complete a Psychiatric Screening Assessment Part 2.

Review of the receiving hospital's ED record for Pt # 16 revealed: "...pt checked into (Name of Hospital) for alcohol detox this morning. Passed out this morning...possible seizure activity was hypotensive on scene (70s)...loss of consciousness about 1 minute while he was on his way to (Name of Hospital)...He appears jaundiced, chronically ill, cachectic...very significant electrolyte derangements...is critically ill and is being transferred to the ICU...."

Pt # 17

The hospital EMTALA Log, did not contain documentation of Pt # 17's arrival or departure. An RN completed a Medical History Part I form and a portion of a transfer form, dated 8/13/15. The transfer form contained documentation: "...nature of the emergency/medical condition is: elevated vitals, bilat lower leg swelling...Mode of Transfer...Ambulance...BP (Blood Pressure) 215/108...Name of Receiving Facility: (Name of Acute Medical Hospital)..." An Evaluator did not complete a Psychiatric Screening Assessment Part 2.

Review of the receiving hospital's ED record for Pt # 17 revealed: "...Sent from (Name of Hospital) after he presented (with) (complaints of) feeling suicidal without a plan. Hx (History) of htn (hypertension), did not take medications today...Bilateral lower extremity swelling and redness that started last night...Impression and Plan...Diagnosis...Cellulitis...Depression...Suicidal thoughts...."

The Director of A and R confirmed that Pt #s 16 and 17 did not have complete Medical Screening Examinations prior to transfer to acute medical hospitals.

2. Review of hospital policy titled EMTALA-Screening, Stabilization and Transfer of Individuals with Emergency Medical/Psychiatric Conditions revealed: "...Qualified Medical Personnel - Personnel designated as such in approved hospital bylaws, rules and regulations or policy, and in accordance with federal and state regulations. Hospital resources and staff available to inpatients at the hospital for emergency services must be available to individuals coming to the hospital for examination and treatment...of emergency medical conditions because these resources are within the capacity of the hospital...All individuals who come to the Hospital's dedicated emergency department for assistance with a medical condition, or come on hospital property for assistance with an emergency medical condition, will receive a medical screening exam and appropriate stabilizing treatment performed by a Qualified Medical Person prior to any decisions regarding admission, discharge, transfer, or referral...."

The hospital policy titled "Qualified Medical Professional Training," effective 03-01-2014, developed by the Admission and Referral (A&R) (Emergency Services) department revealed: "POLICY: (Hospital) will provide training to ensure staff competency when performing emergency medical assessment to patients that present to the hospital seeking treatment...(Hospital) will provide training to ensure staff competency when performing emergency medical assessment to patients that present to the hospital seeking treatment. PROCEDURE: 1. Staff that demonstrate competency and have been approved by the Medical Staff will be deemed Qualified Medical Personnel (QMP). 2. Only staff that have been designated as a QMP will perform emergency medical assessments to those patients that present to the hospital seeking treatment...."

Review of hospital documents revealed that Intake/Admissions Specialist # 1, an RN, completed the Medical History Part-I for Pt #s 9, 16 and 17 prior to these patients being transferred. RN # 8 completed the Medical History Part- I for Pt # 10 prior to her transfer. The hospital was unable to provide documentation that Intake/Admissions Specialist # 1 (RN) or RN # 8 were designated in the hospital medical staff bylaws, rules and regulations or hospital policy as Qualified Medical Persons (QMP).

Review of hospital documents revealed that RN # 8 completed the Medical History Part -I- for Pt # 8 and that Intake/Admissions Specialist # 8 completed the Psychiatric Screening Assessment prior to Pt # 8's transfer. The hospital was unable to provide documentation that RN # 8 or Intake/Admissions Specialist # 8 were designated in the hospital medical staff bylaws, rules and regulations or hospital policy as QMPs.

The Director of Risk Management, responsible for hospital quality, confirmed during an interview conducted on 9/17/15, that neither the Medical Staff By-Laws, Rules and Regulations, nor hospital policies designated non-physician individuals to be approved as QMPs in the hospital. There was no documentation which indicated that non-physician individuals functioning as QMPs had approval from the governing authority to function as QMPs.

Review of Assessment and Referral (A&R) (emergency services) monthly meeting minutes beginning with January, 2015 though August, 2015, revealed that the Medical Director of the hospital and the emergency services department was not in attendance at any of the meetings.

The Director of A&R acknowleged, during interview conducted on 09-18-15, that the Medical Director of emergency services had not attended any of the meetings.

The Director of Risk, responsible for hospital quality, acknowledged during interview conducted on 09-18-15, that the Medical Director was responsible for emergency cases at the hospital. The Director of Risk acknowledged that the Medical Director did not determine there was a concern for potential EMTALA violations at the hospital.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on review of hospital policy/procedure, hospital documents and interview, it was determined that the hospital failed to provide stabilizing treatment, determine stability for transfer, or document the benefit of transfer to a different level of care for evaluation, stabilization and/or treatment for 15 of 18 patients who were transferred to outside medical facilities (Pt #s 1, 22, 11, 19, 20, 21, 23, 7, 8, 9, 10, 12, 13, 16 and 17).

Findings include:

The hospital's policy titled "EMTALA-Screening, Stabilization and Transfer of Individuals with Emergency Medical/Psychiatric Conditions" revealed: "...To Stabilize: To either provide such medical treatment of the condition necessary to completely resolve the individual's emergency medical condition, or to assure, within reasonable medical probability that no material deterioration of the condition is likely to result from, or occur during, transfer of the individual from the facility...All individuals who come to the Hospital's dedicated emergency department for assistance with a medical condition, or come on hospital property for assistance with an emergency medical condition, will receive a medical screening exam and appropriate stabilizing treatment performed by a Qualified Medical Person prior to any decisions regarding admission, discharge, transfer, or referral...."

Review of hospital form titled EMTALA/Transfer Record revealed
spaces for a QMRP to mark: "...I certify that the patient has been stabilized to the best of our ability..." and "...The patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide, for the purpose of evaluating, stabilizing and/or treating the patient's medical condition...."

Review of hospital documents revealed that the following 15 patients presented to the hospital for assistance with medical and/or psychiatric conditions and were transferred to outside medical facilities:
Pt #s 1, 22, 11, 19, 20, 21, 23, 7, 8, 9, 10, 12, 13, 16 and 17).

(Refer to Tag 2406 for information regarding the failure of the hospital to provide completed medical screening examinations for Pt #s 1, 22, 11, 19, 20, 21, 23, 7, 9, 10, 12, 13, 16 and 17).

Refer to Tag 2409 for information regarding the failure of the hospital to provide appropriate transfer of Pt # 8.

The hospital was unable to provide transfer records designating stability for transfer, or documentation of the benefit of transfer to a different level of care for evaluation, stabilization and/or treatment for any of the above 15 patients.

The Director of A and R confirmed, during interview conducted on 9/16/2015, that the EMTALA/Transfer Record form is utilized to document either patient stability for transfer or transfer without stabilization to a different level of care. She confirmed that the forms had not been utilized for patient transfer or were not completed for the 15 patients listed above.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on review of hospital policy/procedure, hospital documents and interview, it was determined that the hospital failed to conduct appropriate transfers for 18 of 18 patients who presented to the hospital for assistance with a medical/psychiatric condition as evidenced by:

1. failure to document a certification that the medical benefits outweighed the increased risks of transfer to the patient, signed by a physician or signed by a QMP and countersigned by a physician for 18 of 18 patients as required by hospital policy ( Pt #s 8, 1, 22, 11, 19, 20, 21, 23, 7, 12, 13, 14, 15, 18, 9, 10, 16 and 17);

2. failure to obtain and document verbal agreement of the receiving hospital/medical facility and physician to accept the transfer for 12 of 18 patients as required by hospital policy (Pt # s 1, 22, 11, 19, 20, 21, 23, 7, 8, 9, 10 and 16); and

3. failure to obtain written consent for transfer for 17 of 18 patients by the patient or their individual representative as required by hospital policy (Pt # s 1, 22, 11, 19, 20, 21, 23, 7, 8, 12, 14, 15, 18, 9, 10, 16 and 17).

Findings include:

1. Review of hospital policy/procedure titled EMTALA-Screening, Stabilization and Transfer of Individuals with Emergency Medical/Psychiatric Conditions: revealed: "...If a physician determines that an immediate transfer of the individual is medically appropriate, a certification that the medical benefits outweigh the increased risks of transfer to the individual will be documented and signed by the physician...If physician instructions are obtained by phone, the certification required above and the physician orders shall be documented by a non-physician QMP receiving the instructions and countersigned by the physician following the transfer, within such time set forth in the hospital's medical staff bylaws or rules and regulations...."

Pt # 8 (a minor)

The hospital EMTALA Log, dated 4/12/15, contained documentation that Pt # 8 arrived by car for "depression". She was "referred to (Name of Acute Medical Hospital ED)..." due to "No Beds." Her mode of departure was not documented on the Log.

Review of hospital document titled (Name of Hospital) Psychiatric Screening Assessment Part 2 revealed: "...S/I w/plan and means/intent...referred to (Name of Crisis Stabilization Unit) or ED...Brought in by her parents for SI (with) plan to cut herself or OD (Overdose)...Pt reports she has cuts on both thighs...Pt does not feel safe-since (Name of Hospital) has no open beds, parents were told to take pt either next door to (Name of Acute Medical Hospital ED) or to go to (Name of Crisis Stabilization Unit)...."

Review of the receiving acute medical hospital's ED record for Pt # 8 revealed: "...Pt reports wanting to kill self by taking pills or slitting throat for 2 weeks...Eminent (sic) risk to self; unable to agree to keep safe...willing to go to (Name of Sending Hospital)...."

Pt # 8 required psychiatric hospitalization , but when she and her parents presented to the hospital, they were referred to a medical hospital ED or a crisis stabilization facility, which is a lower level of care, due to lack of capacity.

The Director of A and R confirmed during interview conducted on 9/17/2015, that A and R staff transferred (suicidal) Pt # 8 to a medical hospital ED or crisis stabilization facility when the hospital had no available beds.

The hospital was unable to provide a certification that the medical benefits outweighed the increased risks of transfer to Pt # 8, documented and signed by a physician or QMP.

Review of hospital documents revealed that the following 17 patients presented to the hospital for assistance with medical and/or psychiatric conditions and were transferred to outside medical facilities: ( Pt #s 1, 22, 11, 19, 20, 21, 23, 7, 12, 13, 14, 15, 18, 9, 10, 16 and 17).

(Cross Reference Tag 2406 for information recorded on the hospital EMTALA Logs, for information regarding the failure of the hospital to provide medical screening examinations for each of the above listed patients and for information, if available, provided by the receiving hospitals and/ or original sending hospitals.

The hospital was unable to provide documented, signed certification by a physician or designated QMP that the medical benefits outweighed the risks of transfer for the 17 patients listed above.

The hospital was able to provide EMTALA/Transfer Records for Pt #s 12, 13, 14, 15, 16, 17 and 18. These Transfer Records contained the required information regarding the medical benefits outweighing the risks of transfer, however, they were not signed by a designated QMP or physician.

The Director of Risk Management confirmed, during interview conducted on 9/17/2015, that the hospital's medical staff had not designated, in the bylaws, rules and regulations or policies, QMP's to sign certifications related to transfers. She also confirmed that physicians had not documented signed certification that the medical benefits outweighed the risks of transfer for the 17 patients listed above.

2. Review of hospital policy titled EMTALA-Screening, Stabilization and Transfer of Individuals with Emergency Medical/Psychiatric Conditions revealed: "...Prior to transfer, hospital staff will obtain the verbal agreement of the receiving hospital and physician to accept the transfer. The facility shall document its communication with the receiving hospital, including the date and time of the transfer request and the name of the person accepting the transfer on the EMTALA Transfer Record...in order to finalize the transfer, the receiving hospital must: a) accept the transfer; b) agree to provide appropriate treatment for the individual; c) have the capability to treat the individual...The transferring hospital should document on the EMTALA Transfer Record the following information: a) the receiving facility's agreement to accept the individual...."

Refer to information in # 1 above regarding Pt # 8 and her transfer to an acute medical hospital. The hospital did not have documented evidence that receiving hospital agreed to accept Pt # 8.

Review of hospital documents revealed that the following 17 patients presented to the hospital for assistance with medical and/or psychiatric conditions and were transferred to outside medical facilities: ( Pt #s 1, 22, 11, 19, 20, 21, 23, 7, 12, 13, 14, 15, 18, 9, 10, 16 and 17).

(Cross Reference Tag 2406 for information recorded on the hospital EMTALA Logs, for information regarding the failure of the hospital to provide medical screening examinations for each of the above listed patients and for information, if available, provided by the receiving hospitals and/or original sending facility.

The hospital was able to provide EMTALA/Transfer Records for Pt #s 12, 13, 14, 15, 16 and 18. These Transfer Records contained the required information regarding acceptance by the receiving facility. However; they were not signed by a physician or designated QMP.

The Director of Risk Management confirmed, during interview conducted on 9/17/2015 that the Transfer Records of the above 6 patients were not completed by a physician or designated QMP.

The hospital was unable to provide documentation of acceptance by the receiving facility for the other 12 patients.

The Director of A and R confirmed during interview conducted on 9/18/2015 that the hospital did not have documented evidence of acceptance by the receiving facility of the transfer of Pt # s 8, 1, 22, 11,19, 20, 21, 23,7, 9, 10 and 17.

3. Review of hospital policy titled EMTALA-Screening, Stabilization and Transfer of Individuals with Emergency Medical/Psychiatric Conditions revealed: "...Prior to transferring an individual with an emergency medical condition, hospital staff will review with the individual or the individual's parent/guardian the risks and benefits of transfer to the second facility. The hospital staff should discuss with the individual or the individual's representative, the right to refuse the transfer. The individual (or representative) should sign the Patient's Consent/Request/Refusal Transfer form...."

Review of hospital documents revealed that the following 17 patients presented to the hospital for assistance with medical and/or psychiatric conditions and were transferred to outside medical facilities: ( Pt #s 8, 1, 22, 11, 19, 20, 21, 23, 7, 12, 14, 15, 18, 9, 10, 16 and 17).

The hospital was unable to provide documentation of signed consent for transfer by any of the above listed 17 patients or their individual representatives.

The Director of A and R confirmed, during interview conducted on 9/16/15, that the hospital had not obtained written consent for transfer from the 17 patients listed above, as required by hospital policy.