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.

CENTERSTONE OF FLORIDA 2020 26TH AVE E BRADENTON, FL Dec. 9, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on medical record review, staff interview and review of facility policy and procedures it was determined the facility is not in compliance with 42 CFR 489.24.

1. The facility failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed for thirteen (#'s 1, 2, 4, 5, 6, 9,10,11,12,13,14,15 and 20)) of twenty (20) patients sampled (see A2406).

2. The facility failed to provide stabilizing treatment to one (#14) of twenty patients sampled (see A2407).

3. The facility failed to ensure a proper transfer was completed for five (#1, 2, 3,13, & 14) of twenty patients sampled (see A2409).
VIOLATION: POSTING OF SIGNS Tag No: A2402
Based on observation and staff interview it was determined the facility failed to ensure the facility post, in a conspicuous place in the emergency service area likely to be noticed by all individuals entering the area, a sign specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and information indicating whether or not the hospital participates in the Medicaid program under a State plan approved under Title XIX.

Findings included:

Tour of the facility's emergency service area, referred to by the facility as the Access area, was conducted on 12/09/2016 at approximately 3:10 p.m. with the Director of Inpatient Admissions. Observation of the area where individuals presented for emergency services and care revealed no evidence of signage stating a patient's right to emergency services. Observation of the area revealed no evidence of signage indicating whether or not the hospital participated in the Medicaid program under a State plan approved under Title XIX. Interview with the Director of Inpatient Admissions at the time of the tour confirmed the observation.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record reviews, on call schedule review, Hospital License review, staff interviews, and review of policy and procedures, and review of Centerstone Professional Ethics, Privileging, and Education Committee Plan it was determined the facility failed to ensure an appropriate medical screening examinations within the capability of the hospital was conducted by an individual(s) determined qualified by the facility Bylaws to determine whether or not an emergency medical condition existed for thirteen (#1, #2, #4, #5, #6, #9, #10, #11, #12, #13, #14, #15, #20) of twenty patients sampled.

Findings included:

Review of the facility policy "Screening and Admissions Policy" dated 2/25/2016 and approved by the Medical Staff. The policy revealed in part, "CENTERSTONE has designated the Access Center as the area of the hospital campus utilized to conduct screenings and assessments. The Access Center has approximately 2000 square feet of space that allows for privacy and freedom of distraction during the interview process. The Access Center is accessible to transportation to voluntary clients as well as law enforcement vehicles and ambulances." The policy also stated in section III Standards and Procedures (A) Screening Process (3) Screener and Supervisor Qualifications: Access Counselors will have at least a Bachelor's degree or be a Registered Nurse with a minimum of 2 years experience in a related field. The Access Counselor will complete on-the-job training and shall be under the supervision of a Licensed Mental Health Professional.

Review of the thirteen (13) sampled patients' medical records revealed a Bachelor prepared Access Counselor completed a screening examination of the patients presenting for examination and treatment. Review of the medical records revealed no evidence the Access Counselor was under the supervision of a Licensed Mental Health Professional to determine if an emergency medical condition existed and if an emergency medical condition was determined to exist, provided any necessary stabilizing treatment or an appropriate transfer.

The Centerstone Professional Ethics, Privileging, and Education Committee Plan (PEPEC), January 2016 (By-Laws) approved by the PEPEC chairperson, Medical Director, Chief Executive Officer, and the Board of Directors. The plan revealed in part, "Introduction ...The plan is adopted to assure the delivery of quality patient/client care throughout the corporation: ... III Definitions: ...Direct Clinical Supervision- Clinical Supervisory status whereby a non-licensed , non-privileged clinician is required to review his/her clinical practice with the licensed privileged clinical/supervisor on a regular basis to assure delivery of appropriate quality services ...Privileges-Clinical activities for which a PEPEC privileged individual competent to perform without supervision, and as approved by the Board of Directors ...XIII. Role and Responsibilities of Professional Staff in Providing Patient Care: A. Physician: The Centerstone Physician ...The physician may work in the hospital ...provide physical assessments and medical consults. B. Psychiatrist: ...The psychiatrist provides psychiatric assessments and psychiatric treatment including medication therapy in hospital and outpatient settings ...C. Psychologist: ...As a psychologist , he/she may provide psychological examinations, testing, psychotherapies and other privileges as qualified ...D. Advanced Registered Nurse Practitioner (ARNP): Centerstone licensed or registered ARNP's may provide all nursing, psychiatric assessments, treatments consistent with the scope of practice ...E. Resident: ...The resident may work in hospital ...and provide physical assessments and medical consults along with other duties as assigned by, and signed off by the attending physician(s) ... F. Physician Assistant (PA) licensed may provide psychiatric assessments, treatments consistent with the scope of their license ...G. Licensed Clinical Social Worker, Marriage and Family Therapist, and Mental Health Counselor: ...may provide direct services in various settings. Clinician may provide psychotherapies and other privileges within the scope of Florida licensure laws." The facility's PEPEC plan approved by the board of directors did not approve or list the Access Counselors as individuals qualified to conduct/perform medical screening examinations for patients who presented to the hospital's Access area requesting/seeking medical care.

Review of the hospital's license, Effective: 08/11/2016, Expires: 04/23/2016. Class 3 Hospital, Adult Psych: 22; Adult Substance Abuse; 15 Total Capacity: 37; Emergency Services: Psychiatry.

1. Review of the medical record for patient #1 revealed the patient (MDS) dated [DATE] with complaints of paranoia with the potential return of hallucinations; wants to get back on medications; can't afford them; and having difficulty concentrating, as stated by the patient. Review of the level of care assessment, performed by the Access Counselor, dated 12/03/2016 stated the recommended level of care was inpatient mental health treatment.

Review of the medical record revealed no evidence the Access Counselor was under the supervision of a Licensed Mental Health Professional As this resulted in an inappropriate medical screening examination as evidenced by failing to ensure the medical screening examination was provided by a qualified medical personnel for patient #1.

Review of the medical record revealed no evidence the physician was consulted. A Review of the physician weekday and weekend on-call schedule verified a physician was on-call on 12/3/2016 when patient #1 presented to the hospital.

2. Review of the medical record for patient #2 revealed the patient (MDS) dated [DATE] escorted by law enforcement. Review of the level of care assessment completed by the Access Counselor stated the patient had active psychotic behavior and complained of widespread pain and tingling in his arm/fingers. Review of the level of care assessment, performed by the Access Counselor, dated 11/27/2016, stated the recommended level of care was outpatient mental health treatment. Documentation by the Access Counselor revealed the patient was transferred for medical clearance related to the patient's complaint of widespread pain and tingling in his arm/fingers.

Review of the medical record revealed no evidence the Access Counselor was under the supervision of a Licensed Mental Health Professional. The medical screening examination was not conducted by a qualified medical personnel for Patient #2.

3. Review of the medical record for patient #4 revealed the patient (MDS) dated [DATE] requesting treatment for substance abuse. Review of the nursing assessment, dated 7/23/2016, stated the recommended level of care was outpatient detox treatment, however the patient felt he needed inpatient detox. Documentation revealed the facility did not have available beds for admission and the patient was observed overnight in the Access area. On 7/23/2016 the patient was re-evaluated. Documentation revealed the patient requested to leave and signed a no harm contract.

Review of the medical record revealed no evidence the Access Counselor or RN (Registered Nurse) was under the supervision of a Licensed Mental Health Professional. As this resulted in an inappropriate medical screening examination as evidenced by failing to ensure the medical screening examination was provided by a qualified medical personnel for patient #4. Review of the medical record revealed no evidence the physician was consulted. Review of the physician weekday and weekend on-call schedule validated a physician was on-call on 07/22/2016 when patient #4 presented to the hospital.

4. Review of the medical record for patient #5 revealed the patient (MDS) dated [DATE] with complaints of anxiety and depression. Documentation revealed the patient stated a physician from a local clinic referred the patient to the facility for evaluation and concern for the patient's safety. Review of the level of care assessment, performed by the Access Counselor, dated 7/28/2016, stated the patient denied suicidal ideations and the patient's parent believed the patient was safe to discharge home. Review of the record revealed the patient had an outpatient appointment scheduled for 7/29/2016, signed a no harm contract and was discharged home with the mother.

Review of the medical record revealed no evidence the physician was consulted. Review of the physician weekday and weekend on-call schedule verified that a physician was on-call on 07/28/2016 when patient #5 presented to the hospital.

Review of the medical record revealed no evidence the Access Counselor was under the supervision of a Licensed Mental Health Professional. The facility failed to ensure the medical screening examination was conducted by a qualified medical personal for patient #5 on 7/28/2016.

5. Review of the medical record for patient #6 revealed the patient (MDS) dated [DATE] requesting treatment for alcohol abuse and reported withdrawal symptoms of [DIAGNOSES REDACTED].

Review of the medical record revealed no evidence the physician was consulted. Review of the physician weekday and weekend on-call schedule verified that a physician was on-call on 08/02/2016 when patient #6 presented to the hospital. Review of the medical record revealed no evidence the Access Counselor was under the supervision of a Licensed Mental Health Professional. As this resulted in an inappropriate medical screening examination as evidenced by failing to ensure the medical screening examination was provided by a qualified medical personnel for patient #6.

6. Review of the medical record for patient #9 revealed the patient (MDS) dated [DATE] requesting treatment for mental health concerns, anxiety and stress. The patient reported they were almost out of anti-anxiety medication. The patient reported if they did not get more they would go into a psychosis due to panic attacks. Review of the level of care assessment, performed by the Access Counselor, dated 9/29/2016 stated the patient did not meet admission criteria and recommended outpatient treatment. Documentation revealed the patient was provided a referral, signed a contract for safety and was discharged .

Review of the medical record revealed no evidence the physician was consulted. Review of the physician weekday and weekend on-call schedule on 09/29/2016 revealed that a physician was on-call when patient #9 presented to the hospital. Review of the medical record revealed no evidence the Access Counselor was under the supervision of a Licensed Mental Health Professional. As this resulted in an inappropriate medical screening examination as evidenced by failing to ensure the medical screening examination was provided by a qualified medical personnel for patient #9.

7. Review of the medical record for patient #10 revealed the patient (MDS) dated [DATE] with complaint of depression, stress and requested treatment for mental health concerns. Review of the level of care assessment, performed by the Access Counselor, dated 9/22/2016 stated the patient (a minor) and the parent agreed the patient did not require inpatient treatment. Documentation revealed the patient and parent signed a contract for safety, a referral for outpatient treatment was provided and the patient was discharged .

Review of the medical record revealed no evidence the physician was consulted. Review of the physician weekday and weekend on-call schedule on 09/22/2016 revealed that a physician was on-call when patient #10 presented to the hospital. Review of the medical record revealed no evidence the Access Counselor was under the supervision of a Licensed Mental Health Professional. As this resulted in an inappropriate medical screening examination as evidenced by failing to ensure the medical screening examination was provided by a qualified medical personnel for patient #10.

8. Review of the medical record for patient #11 revealed the patient (MDS) dated [DATE] at 8:14 p.m. with complaints of depression, grief, loss. Further review revealed the patient was having current thoughts of suicide, and the form was signed by the patient on 10/7/2016. Review of the record revealed documentation at 10:00 p.m. stating the patient left prior to an assessment. Documentation stated the patient was having suicidal thoughts.

An interview with the Director of Inpatient Admissions was conducted during the medical record review. He stated the process for voluntary patients that arrived for emergency care and services was to greet and request the patient to describe the problem they were seeking help with at the time of arrival. The Director stated the staff member that greeted the patient would alert the Access Counselor the patient was suicidal. At that time the Counselor would assess the patient and escort the patient to a secure area for the safety of the patient and others if the patient was suicidal or homicidal. The Director confirmed the facility did not have a policy that outlined the process to follow for patients that arrive to the facility with complaints of suicide or homicide.

Review of the medical record revealed no evidence the facility ensured continued monitoring of the patient, identified as suicidal, until it could be determined whether or not the patient had an EMC (Emergency Medical Condition). Review of the medical record revealed no evidence the physician was consulted in the case, once it was determined from the patient's assessment as having suicidal thoughts. Review of the Physician weekday and weekend on-call schedule revealed that a physician was on call on 10/07/2016, when patient #11 presented to the hospital. The hospital failed to ensure that an appropriate medical screening examination was provided by a qualified medical personnel for patient #11, when she presented to the hospital with complaints of suicidal thoughts.

9. Review of the medical record for patient #12 revealed the patient (a minor) (MDS) dated [DATE] requesting treatment for substance abuse. Review of the level of care assessment, performed by the Access Counselor, dated 10/05/2016 revealed the patient was provided a referral for outpatient treatment.

Review of the medical record revealed no evidence the physician was consulted. Review of the Physician weekday and weekend on-call scheduled verified a physician was on-call when patient #12 (MDS) dated [DATE]. Review of the medical record revealed no evidence the Access Counselor was under the supervision of a Licensed Mental Health Professional. This resulted in an inappropriate medical screening examination for Patient #12 on 10/5/2016, as evidenced by failing to ensure the medical screening examination was conducted by a qualified medical personnel.

10. Review of the medical record for patient #13 revealed the patient (MDS) dated [DATE] escorted by law enforcement and held under the Baker Act 52 for suicidal ideations. Review of the record revealed no evidence an Access Counselor conducted a level of care assessment. Documentation by an Access Counselor at 4:15 p.m. stated due to lack of bed space, arrangement was made to transfer the patient to another facility for treatment.

Review of the medical record revealed no evidence the physician was consulted. Review of the Physician weekday and weekend on-call schedule dated 10/9/2016 revealed that an on-call physician was available when patient #13 presented to the hospital. Review of the medical record revealed no evidence the Access Counselor was under the supervision of a Licensed Mental Health Professional. The patient was not seen by a psychiatrist. Therefore, the hospital failed ensure that an appropriate medical screening examination was conducted by a qualified medical personnel for patient #13 on 10/09/2016.

11. Review of the medical record for patient #14 revealed the patient (MDS) dated [DATE] requesting treatment for substance abuse. Documentation revealed the patient reported a history of [DIAGNOSES REDACTED] and was currently using 1-3 bags of heroin. Review of the level of care assessment, completed on 10/09/2016 stated the patient met inpatient admission criteria but the facility did not have any available beds. Documentation by the Access Counselor stated the patient was discharged and informed to return the following day to inquire if the facility had bed availability for admission.

Review of the medical record revealed no evidence the physician was consulted. Review of the Physician weekday and weekend on-call schedule dated 10/9/2016 revealed that an on-call physician was available when patient #14 presented to the hospital. Review of the medical record revealed no evidence the Access Counselor was under the supervision of a Licensed Mental Health Professional. The patient was not seen by a psychiatrist. Therefore, the hospital failed to ensure that an appropriate medical screening examination was conducted by a qualified medical personnel for patient #14 on 10/09/2016.

12. Review of the medical record for patient #15 revealed the patient (MDS) dated [DATE] at 9:18 a.m. requesting treatment for complaint of increased stress and mental health evaluation. Review of the level of care assessment, completed on 11/10/2016, by the Access Counselor revealed the patient was evaluated and referred to outpatient treatment.

Review of the medical record revealed no evidence the physician was consulted. Review of the Physician weekday and weekend on-call schedule dated 11/10/2016 revealed that an on-call physician was available when patient #15 presented to the hospital. Review of the medical record revealed no evidence the Access Counselor was under the supervision of a Licensed Mental Health Professional. The patient was not seen by a psychiatrist. Therefore the hospital failed to ensure that an appropriate medical screening examination was conducted by a qualified medical personnel for Patient #15 on 11/10/2016.

13. Review of the medical record for patient #20 revealed the patient (MDS) dated [DATE] with complaints of stress and requested an evaluation. Review of the level of care assessment, completed by the Access counselor on 12/09/2016 stated the patient presented with a swollen ankle and expressed it was painful to walk. Documentation stated the patient was referred to the acute care hospital for left ankle pain and to rule out a fracture. Documentation revealed the facility transported the patient to an acute care hospital.

Review of the medical record revealed no evidence the physician was consulted. Review of the physician weekday and weekend on-call schedule verified that a physician was available and on call when patient #20 presented to the hospital. Review of the medical record revealed no evidence the Access Counselor was under the supervision of a Licensed Mental Health Professional. As this resulted in an inappropriate medical screening examination for patient #20 as evidenced failing to ensure the medical screening examination was conducted by a qualified medical personnel.

An interview was conducted with the Director of Admissions on 12/09/2016 at approximately 4:15 p.m. and each of the medical records were reviewed. The above findings were confirmed by the Director of Admissions.

During the observational tour of the Access area on 12/9/2016 at 3:15 accompanied by the Access Supervisor stated all patients that presented to the facility are assessed to determine their level of care and services required. He stated the intake area was staffed 24/7 and an on-call physician was available 24/7.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, on call Physician schedules, and staff interview it was determined the facility failed to ensure that stabilizing treatment within the capability of the staff and facilities available at the hospital for further medical examination and treatment was provided as required to stabilize the medical condition for one (#14) of twenty patients sampled.

Findings included:

Review of the medical record for patient #14 revealed the patient (MDS) dated [DATE] and requested treatment for substance abuse, because he was addicted heroin. Documentation revealed the patient reported a history of [DIAGNOSES REDACTED] and was currently using (injecting) 1-3 bags of heroin per day.

Review of the level of care assessment, completed on 10/09/2016 by an Access Counselor, stated the patient met inpatient detox admission criteria but the facility did not have any available beds. Documentation by the Access Counselor stated the patient was discharged and informed to return the following day to inquire if the facility had bed availability for admission.

Review of the medical record revealed no evidence the physician was consulted to provide evaluation and treatment once it was determined; the patient met in-patient criteria for admission for treatment. Review of the Physician weekday and weekend on-call schedule dated 10/9/2016 verified that an on-call physician was available when patient #14 presented to the hospital.

The facility failed to ensure that prior to discharge stabilizing treatment within the capability (on-call physician) provided stabilizing treatment as required for patient #4 on 10/09/2016.

An interview with the Director of Admissions on 12/09/2016 at approximately 4:00 p.m. confirmed the above findings.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, bed census reports review, on call schedules review, policy and procedure review, and staff interview it was determined the facility failed to ensure appropriate transfer to another medical facility by not providing the individual of the risks and benefits of transfer and failed to ensure a physician signed transfer certification of the medical benefits reasonably expected at another medical facility outweighed the increased risks from being transferred; failed to provide documentation that acceptance was obtained from the receiving hospital; failed to send the receiving the hospital copies of the medical records related to the emergency condition; and failed to provide documentation that the receiving facility has available space and qualified personnel for the treatment of individuals for five (#1, #2, #3, #13, and #14) of twenty patients sampled. The facility failed to ensure that an appropriate transfer by failing to provide medical treatment that was within its capacity that minimized the risks of the individual's health for an individual who was unstable for one (#14) of twenty sampled patients, instead the patient was discharged .

Findings included:

The facility's Policy and Procedure titled, Medical Standards for Admission to Cornerstone Hospital and Crisis Center, Policy: II.B15.14.CFL, Date: 02/25/16 was reviewed. The policy revealed in part, "Policy: It is the policy of the Centerstone Hospital and Crisis Center to admit persons for treatment whose physical health status is stable enough that it will not be compromised during the patients stay in the facility. II. Purpose: A. To identify common medical problems of patients who are referred to this facility which may require additional workup or treatment prior to accepting a patient. To assure that patient's medical needs receive priority and are addressed prior to accepting the patient ...III. Procedures: A. All persons presenting or referred to Centerstone Hospital and Crisis Center for admission shall be screened for medical stability during the admission process. Those patients assessed as being "medically unstable" shall be sent to an acute care facility for medical emergency evaluation after screening by a R.N. (Registered Nurse). An RN from the hospital unit must assess questionable consumer when no Access Center nurse available and complete the following steps: 1. The psychiatrist will be consulted as to necessity to transfer to the E.R. (emergency room ) and give the order. 2. The RN will call the E.R. to give a report to the triage or charge nurse on the patient being sent for the medical emergency. 3. Access Center Personnel or the Nursing Unit RN will complete the "Patient Agreement to Transfer" form ... 4. The RN will complete the Hospital Transfer form (#AC-053) in its entirety up to the black dotted line ...5. The white copy of the transfer form will go with the patient ... 6. Consent will be obtained by the consumer/patient prior to transport to E.R. for medical evaluation and release of information on form #MG-102 ...7. The original consent will accompany the consumer/patient ...B. The Director of Nursing, Charge nurse manager or Access RN will facilitate doctor to doctor reports when deemed necessary."

1. Review of the medical record for patient #1 revealed the patient (MDS) dated [DATE] with complaints of paranoia with the potential return of hallucinations and seeking treatment. Review of the level of care assessment, dated 12/03/2016 stated the recommended level of care was inpatient mental health treatment.

The Access Counselor arranged transfer of the patient to another facility due to lack of capacity. Review of the hospital census dated 12/3/2016 revealed the hospital had capacity (beds). The bed census report revealed a patient census of 18 on the psychiatric unit, and 22 total beds. As a result there were 4 (four) available beds. Review of the medical record revealed no evidence a transfer order was obtained from a physician to transfer the patient. Documentation revealed the Access Counselor transferred Patient #1 on 12/3/2016 to another facility.

Review of the medical record revealed no evidence the physician was consulted.

Review of the on call schedule dated 12/3/2017 revealed the facility had a physician on call (capability) when the patient presented to the Access area. Review of the medical record revealed no evidence the patient was provided the risks and benefits of transfer to another facility. Review of the medical record revealed no evidence a physician signed a written transfer for certification of the medical benefits reasonably expected at another medical facility outweighed the increased risks from being transferred. There was no documented evidence that transfer paperwork was completed. The facility had the capability and capacity to provide the needed care for patient #1 on 12/3/2016. As this resulted in an inappropriate transfer for patient #1.

2. Review of the medical record for patient #2 revealed the patient (MDS) dated [DATE] by law enforcement for evaluation of psychotic behavior. Review of the level of care assessment dated [DATE] stated the patient had active psychotic behavior and was experiencing pain and tingling. Documentation by the Access Counselor stated the recommended level of care was outpatient mental health treatment.

Review of the level of care assessment revealed the Access Counselor arranged for the patient to be transferred to an acute care facility for medical clearance for complaints of widespread pain and tingling in the arm/fingers. Review of the medical record revealed no evidence a physician order was obtained to transfer patient #2 on 11/27/2016. Review of the medical record revealed no evidence the patient was provided the risks and benefits of transfer to another facility. Review of the medical record revealed no evidence a physician signed the transfer certification of the medical benefits reasonably expected at another medical facility outweighed the increased risks from being transferred. There was no documentation that the hospital had obtained acceptance or that the receiving hospital had available space to provide the needed care for the patient. There was no documentation that transfer paperwork was sent with patient #2 to the receiving hospital on [DATE].

3. Review of the medical record for patient #3 revealed the patient (MDS) dated [DATE] with complaints of suicidal ideation. Review of the medical record revealed the patient was held under the Baker Act 52. Documentation revealed the facility lacked capacity and the patient was transferred.

Review of the medical record revealed no evidence the patient was provided the risks and benefits of transfer to another facility. Review of the medical record revealed no evidence a physician signed the transfer certification of the medical benefits reasonably expected at another medical facility outweighed the increased risks from being transferred. Review of the medical record revealed no evidence a physician order was obtained to transfer patient #3. There was no documentation that the hospital had obtained acceptance or that the receiving hospital had available space to provide the needed care for the patient. There was no documentation that transfer paperwork was sent with patient #3 to the receiving hospital on [DATE].

4. Review of the medical record for patient #13 revealed the patient (MDS) dated [DATE] escorted by law enforcement and detained under the Baker Act 52 for suicidal ideation. Review of the medical record revealed the facility did not have capacity and the patient was transferred to another facility.

Review of the medical record revealed no evidence the patient was provided the risks and benefits of transfer to another facility. Review of the medical record revealed no evidence a physician signed transfer certification of the medical benefits reasonably expected at another medical facility outweighed the increased risks from being transferred. Review of the medical record revealed no evidence a physician order was obtained to transfer patient #13. There was no documentation that the hospital had obtained acceptance or that the receiving hospital had available space to provide the needed care for the patient. There was no documentation that transfer paperwork was sent with patient #13 to the receiving hospital on [DATE].

5. Review of the medical record for patient #14 revealed the patient (MDS) dated [DATE] with complaints of addiction to heroin and seeking detox treatment. Review of the level of care assessment dated [DATE] stated the patient reported they could not afford the drugs anymore and required assistance for detox.

Documentation by the Access Counselor stated the patient met inpatient criteria but the facility lacked capacity.

Review of the medical record revealed no evidence the patient was assessed by a Registered Nurse, no vital signs were obtained and no physician was consulted. Review of the facility's Physician Weekday and Weekend on-call schedule dated 10/09/2016, verified the facility had a physician on-call to evaluate patient #14 for transfer.

Review of the record revealed the facility failed to effect an appropriate transfer of the patient who met in-patient admissions criteria, and was unstable prior to discharge. The Access Counselor documented the patient was discharged and informed to return to the facility the next day to inquire about the facility's capacity and ability to admit. The facility failed to appropriately transfer patient #14 on 10/09/2016 to an appropriate facility for needed care, for his unstable medical condition.

An interview with the Director of Inpatient Admissions on 12/9/2016 at approximately 4:15 p.m. confirmed the above findings after review of the medical records.

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to appropriately transfer patient #1, #2, #3, #13 and #14.