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.

LAKESIDE BEHAVIORAL HEALTH SYSTEM 2911 BRUNSWICK RD MEMPHIS, TN April 6, 2018
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the Psychiatric hospital's Intake Assessment Department (also known as their hospital emergency department area) seeking medical attention received an appropriate Medical Screening Examination (MSE) to determine if an emergency medical condition existed for 18 of 20 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 18, 19 and 20) patients presenting to the hospital's ED seeking medical attention.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the Intake Assessment Department of the Psychiatric hospital (also known as their Emergency Department area) seeking medical attention received an appropriate Medical Screening Examination (MSE) to determine if an emergency medical condition (EMC) existed for 18 of 20 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 18, 19 and 20) sampled ED patients.

The findings included:

1. Review of the facility "EMTALA [Emergency Medical Treatment And labor Act] - Medical Screening Examination [MSE] and Stabilization" policy revealed, "...PURPOSE: When an individual comes to a dedicated emergency department (DED) and a request is made on his or her behalf for an examination or treatment for a medical condition...an appropriate medical screening examination (MSE), within the capabilities of the hospital's DED...shall be performed by an individual qualified to perform such examination to determine whether an EMC exists...If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment...or an appropriate transfer as required by EMTALA and State laws and regulations. Such stabilization treatment shall be applied in a non-discriminatory manner (e.g., no different level of care because of diagnosis, financial status, race, color, national origin, or handicap)...

EXTENT OF THE MSE
1. Determine if an EMC exists. Hospitals are obligated to perform the MSE to determine if an EMC exists...
3. Judgment of physician or QMP [Qualified Medical Personnel]. The extent of the necessary examination to determine whether an EMC exists is generally within the judgment and discretion of the physician or other QMP performing the examination function...
4. An on-going process. The record must reflect continued monitoring according to the individual's needs and must continue until the individual is stabilized or appropriately transferred. This evaluation must be documented in the individual's medical records prior to discharge or transfer. When stabilizing treatment is rendered for an EMC, medical records should indicate the treatment necessary, medications, treatment, surgeries and services provided, and their effect on the EMC, including screenings, tests, evaluations, impressions and diagnoses.
5. Varies by presenting symptoms. The hospital is required only to perform such medical screening within the scope of its capabilities as would be appropriate for any individual presenting...a. Depending on the individual's presenting symptoms, the MSE may range from a simple process...to a complex process that also involves performing ancillary studies...

WHO MAY PERFORM THE MSE:
1. Only the following individuals may perform an MSE:
a. A qualified physician with appropriate privileges; or
b. A qualified licensed independent practitioner (LIP) with appropriate competencies; or
c. A qualified staff member who:
-is qualified to conduct such an examination either through appropriate privileging or demonstrated competencies;
-is functioning with the scope of his or her license and in com...is functioning within the scope of his or her license in compliance with State law and applicable practice acts (e.g., Medical or Nurse Practice Acts);
-is performing the screening examination based on medical staff approved guidelines, protocols or algorithms; and
-is approved by the facility's governing board...

NO DELAY IN MEDICAL SCREENING OR EXAMINATION 1. Reasonable Registration Process. An MSE, stabilizing treatment, or appropriate transfer will not be delayed to inquire about the individual's method of payment or insurance status, or conditioned on an individual's completion of a financial responsibility form...Reasonable registration processes...as long as these procedures do not delay screening or treatment or unduly discourage individuals from remaining for further evaluation...
5. Contacting the individual's physician. An emergency department physician or non-physician practitioner may contact the individual's physician at any time to seek advice regarding the individual's medical history and needs that may be relevant to medical treatment and screening of the individual...
7. Financial Inquiries. Individuals who inquire about financial responsibility for emergency care should receive a response by a staff member who has been well trained to provide information regarding potential financial liability. The staff member who provides information on potential financial liability should clearly inform the individual that the hospital would provide an MSE and any necessary stabilizing treatment, regardless of his or her ability to pay...

ESTABLISHING MEDICAL STABILIZATION The determination of whether an individual is stable is not based on the clinical outcome of the individual's medical condition. An individual is considered stable when:
1. Stable. The physician or QMP treating the emergency has determined that the EMC that caused the individual to seek care in the ED is resolved...
2. Stable for transfer. The physician or QMP treating the individual in the DED has determined within reasonable clinical confidence no material deterioration of the condition is likely, within reasonable medical probability...In the case of an individual with a psychiatric condition, the individual is protected and prevented from injuring himself/herself or others...
3. Stable for discharge. An individual is considered stable for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his or her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient or later as inpatient, provided the individual is given a plan for appropriate follow-up care with the discharge instructions. For the purpose of discharging an individual with psychiatric condition(s), the individual is considered to be stable for discharge when he or she is no longer considered to be a threat to himself or herself or to others."

In addition, the facility "EMTALA [Emergency Medical Treatment And labor Act] - Medical Screening Examination [MSE] and Stabilization" policy revealed the following inaccurate guidance:

"...Who May Perform the MSE...3. Qualified Medical Personnel [QMP]. QMP include licensed or certified social workers, advanced practice registered nurses, registered nurses, physician assistants, psychologists, and other professionals delineated as such in the hospital's governing bylaws if the scope of the EMC is within the individual's scope of practice...
a. Guidelines. Before a QMP may provide an [a] MSE under EMTALA, the governing board must approve, based on recommendations of the Medical Executive Committee, specific screening guidelines, protocols or algorithms that outline the examination and/or diagnostic work-up required to determine if an EMC exists. These guidelines will normally be complaint specific and will be limited to those presenting complaints that lend themselves to screening by such non-physician personnel...
Behavioral Health. QMPs credentialed to perform behavioral health evaluations may be consulted by a physician for the purpose of evaluating if the patient is experiencing a psychiatric disturbance. The bylaws must also establish a protocol for treatment by QMPs (e.g. with review by a physician or other limitations based on condition)...

No Delay in Medical Screening or Examination...
There is NO delay in the provision of an MSE or stabilization if:
a. there is not an open bed in the DED;
b. there are not sufficient caregivers present to render the MSE and/or stabilizing treatment; and
c. the individual's condition does not warrant immediate screening by a physician or QMP..."

2. Review of the "Assessment" policy revealed, "...All patients awaiting assessment will receive a thorough assessment and evaluation and will be assessed and reassessed throughout their assessment waiting period. Procedure: 1. Upon arrival of the individual to our facility for the evaluation...the receptionist will ask the individual/family to complete the Registration paperwork that includes the Triage Form, Communicable Disease Form, HIPPA notification and demographics...5. Upon completion of the assessment...If appropriate, the individual will be given three referrals, unless driven by a Managed Care Company or referral request, with all necessary demographic information to obtain an appointment...6. The recommendations for services will always be based entirely upon clinical necessity of the individual..."

3. Review of the facility medical staff bylaws revealed, "...i. The following mental health professionals are deemed to be credentialed to perform medical screening examinations to determine whether an individual has an emergency medical condition and, therefore, are Qualified mental health Professionals (QMHP): (i) Licensed Physicians; (ii) Licensed Psychologists; (iii) Licensed Social Workers; (iv) Registered Nurses; and (v) Licensed Professional Counselors..."

Review of the Medical Executive Committee (MEC) meeting minutes dated March 23, 2017 revealed the bylaws were approved by the MEC.

Review of the State Health Related Board Statutes for Licensed Psychologists, Licensed Social Workers, Registered Nurses and Licensed Professional Counselors revealed the scope of practices for these disciplines do not allow them to independently practice, treat patients and prescribe medical treatment for patients. Therefore, cannot be considered a Qualified Medical Professional (QMP) or Licensed Independent Practitioner (LIP).

4. Medical record review from Hospital #2 (an acute care hospital) revealed Patient #1 had been a patient at the hospital on [DATE] with diagnoses of Acute Traumatic Minimally Displaced Fractures of the Ribs, Pulmonary Contusion, Alcohol Abuse, and Right Clavicular Fracture.

Review of a blood alcohol test collected at Hospital #2 on 2/6/17 at 8:21 PM revealed Patient #1 had a level of 173 mg/dl (milligrams/deciliter). The normal reference range was 0-10 mg/dl and results greater than 50 mg/dl indicated toxic level.

Review of a physician's progress note from Hospital #2 dated 2/7/17 at 10:54 AM revealed, " ...History of heavy alcohol use..."

Review of a Physical Therapy (PT) Evaluation from Hospital #2 dated 2/9/17 revealed, "...pt [patient] states wife is years older than him and will not be available to assist pt at home in this condition...very fearful of pain and noted to be very anxious ..." Further review of the PT evaluation revealed Patient #1's anticipated discharge disposition was to an inpatient rehabilitation facility.

Review of a Social Worker note from Hospital #2 dated 2/9/17 at 10:06 AM revealed the SW had spoken to Patient #1's wife and determined the wife could not care for him at home.

Review of a SW note from Hospital #2 dated 2/10/17 at 3:14 PM revealed that Patient #1's insurance denied his request for inpatient skilled rehabilitation upon being discharge from Hospital #2.

Patient #1 was discharged home from Hospital #2 on 2/10/17.

a. Review of a referral form from Physician #2 (the patient's orthopedic physician) for Patient #1 revealed Physician #2's nurse had called Hospital #1 (the Psychiatric Hospital) on 2/14/17 at 11:24 AM and to inform them that Patient #1 was "...on his way for detox from alcohol ..."

Review of a "Registration/Information Worksheet" from Hospital #1 revealed Patient #1 was a [AGE] year old male and arrived at Hospital #1 on 2/14/17 at 12:15 PM. Patient #1 signed consent for the staff at Hospital #1 to perform an assessment and to verify his insurance benefits. Review of the Primary Insurance revealed a named insurance carrier and the Secondary Insurance was "self-pay."

b. Review of the "Triage Form - Needs Assessment" completed by Patient #1 revealed he was seeking Inpatient Treatment, Treatment Recommendations, and Medication Management. Patient #1 also documented the following concerns:
Appetite/Sleep Disturbance.
Martial or Relationship Stressor.
Problems at Work.
Feelings of Anger.
Excessive Worry or Unwanted Thoughts.
Difficulty Concentrating.
Depression/Sadness/Crying Spells.
Loss of Interest/Enjoyment in Sexual Activity.
Alcohol or Drug Use.
Easily Annoyed/Irritated/Tense/Nervous.
Temper Outburst/Destructive to Property, and
Impulsiveness/Acting without Thinking.
Patient #1 identified a feeling of wanting to harm self, and a strong/moderate desire to die right now. Patient #1 revealed that his alcohol and marijuana use brought him to Hospital #1 requesting help.

c. Review of the "MEDICAL SCREENING FORM" dated 2/14/17 at 1:40 PM completed by Registered Nurse (RN) #1 documented hypertension, gastrointestinal dysfunction, and current broken bones/fractures as Patient #1's other current medical conditions. The Breathalyzer section was blank.

In an interview on 3/28/18 at 10:20 AM in the conference room, RN #1 verified that when Patient #1 and his wife had arrived at the hospital a Code Yellow had to be called due to a verbal altercation between Patient #1 and his wife. Patient #1's wife also stated she was fearful of Patient #1. RN #1 stated the patient was upset and concerned because his insurance would not cover inpatient treatment.

There was no documentation RN #1 included information related to the Code Yellow in Patient #1's assessment.

d. Review of the "COMPREHENSIVE / PSYCHOSOCIAL ASSESSMENT TOOL - Part 1 (Initial Screening)" dated 2/14/17 beginning at 1:52 PM and completed by Assessor #1 (who had a Master of Arts in Sociology) revealed the following:

Chief Complaint: Assessor #1 documented that Patient #1 stated, "Depression, alcohol" and Patient #1's wife stated, "Severe alcoholism. He's been through DTs [delirium tremens] 4 times in past 4 months." Assessor #1 documented the patient's wife reported the patient drank half a pint of vodka yesterday. Assessor #1 documented, "Pt. reported that life is useless, 'what the F... what does it matter'..."

The "Problems with performing activities of daily living (feeding, bathing, hygiene, dressing)" section revealed Assessor #1 documented that wife reported that Patient #1 needed help with getting dressed, showering, and getting out of bed.

The "Alcohol / Drug Use" section revealed Assessor #1 documented that Patient #1 drank 1 pint of vodka daily with the last use on 2/13/17 at 1:00 PM. Assessor #1 documented that Patient #1 had a history of withdrawals and DTs with the most recent complaint last week.

The "Withdrawal Symptoms/Behaviors from Alcohol/Drug Use" section revealed Assessor #1 documented the patient's symptoms of "shakes...diarrhea...sleeplessness..."
The patient and wife reported when he has the "shakes...when I don't drink...I usually drink and then it quits" with the most recent being last week.
The patient and wife reported the "diarrhea" frequency was "a lot" with the duration of a "couple of days" with the most recent being yesterday, 2/13/17.

The "Abuse, Neglect, or Trauma Assessment" section revealed Assessor #1 documented that Patient #1 had a history of physical and mental abuse by his father during his childhood.

Review of the "INITIAL EVALUATION OF RISK TO SELF/OTHERS" completed by Assessor #1 on 2/14/17 at 2:39 PM, revealed the following:
Suicide Risk Assessment: Assessor #1 documented Patient #1 denied suicidal ideations or plans and wrote that the patient stated, "I don't want to be here but I don't have thoughts of killing myself. I just wish something would take me." In answer to "Previous Hx [history] of Ideation Specify if within the past 6 months" the Assessor documented the patient stated, "...this year..." There was no documentation Assessor #1 further assessed the suicidal ideation the patient had reported as being "this year [less than 2 months into the year]."

The "Weapons Screening" section revealed Assessor #1 documented Patient #1 admitted he had access to weapons, owned a gun, and had guns in the home.
There was no documentation the facility provided safe interventions related to the weapons screening.

The "Accuracy of Reports and History of Risk: Is there any evidence or concern that the patient or others may be concealing or denying current or past Suicide / homicide / assaultive ideation/behaviors?" section revealed Assessor #1 documented "No."
There was no documentation Assessor #1 further assessed the suicidal ideation the patient had reported as being "this year [less than 2 months into the year]." There was no documentation the assessor assessed the wife's fear of the patient.

In the "Suicide and Homicide / Violence Risk Factors" section Assessor #1 documented Patient #1 had the following Risk Factors:
45 years and older.
had possession of weapons.
severe problems with significant others.
history of bipolar disorder.
alcohol or drug use.
hopelessness.
blunted / flat affect.
rapid mood shifts.
severe worry / rumination, and
severe anxiety / panic.
There was no documentation Hospital #1 provided treatment or interventions for these risk factors.

Assessor #1 documented, "Pt is 57, diagnosed with bipolar, very depressed and anxious, abusing alcohol, having marital problems."

The "Internal / External Protective Factors" section revealed Assessor #1 failed to identify if Patient #1 felt safe going home or if Patient #1's wife felt she would be able to keep Patient #1 safe in a home environment.

The "Summary Evaluation of Risk of Suicide / Homicide /Assaultive Behavior / Vulnerability" section revealed Assessor #1 documented that Patient #1 was a "Low to No Risk" for Suicide and Homicide.

Assessor #1 documented she reviewed the assessment via a telephone call with Physician #1 (the on call Psychiatrist at Hospital #1) on 2/14/17 at 2:59 PM.

The patient initially documented he had a moderate-strong desire to "die right now" and feeling of self-harm. Later in the assessment process, Assessor #1 documented Patient #1 had no suicidal or homicidal ideations. There was no documentation Assessor #1 addressed these changes in the patients status.
There was no documentation the assessor identified or provided interventions related to the verbal altercation between Patient #1 and his wife or the wife's fearfulness of the patient.

e. Review of the "Comprehensive/Psychological Assessment Tool - Part 2" form revealed Assessor #1 documented the following:

The "Major Life Areas" section revealed Patient #1 admitted "Problems at Work or School...has missed some work and hasn't been performing well...Deterioration in Hygiene and/or Grooming...Per wife pt doesn't take care of his grooming as well when drinks...Loss of Energy or Interest in Activities...for past 3 months...Social Withdrawal...has lost interest in everything...Isolating from everyone for past 3 months..."

The "Behavior Changes" section revealed Patient #1 admitted "Irritability Poor Impulse Control...per wife- impulsive-drives his motorcycle under the influence. buys scratch offs [lottery tickets] daily...increase in irritability for more than 3 months..."

The "Sleep" section revealed Patient #1 admitted "Not sleeping...'I've gone days'...Difficulty Going to Sleep (Initial Insomnia)...mind races...has to get up at 3 am for work..."

The "Eating" section revealed Patient #1 admitted "...Compulsive Overeating...daily...loss of appetite for past 3 months..." Assessor #1 documented the patient had lost 50 pounds in the past 3 months.

The "Anxiety" section revealed Patient #1 admitted "Panic Attacks...'All the time' up to 10 times a day at work...Obsessive/Compulsive Thoughts...could be anything..." the "Anxiety scale", with "1 meaning no anxiety and 10" is the worst, rate your anxiety." The patient's anxiety level scale was documented to be a "10...when having anxiety attacks...5-in general." There was no documentation the facility treated or addressed the patient's identified anxiety levels.

The "Family Assessment" section documented the patient lived "with wife but they don't stay in the same room. Wife reports that she is his care taker and is codependent..." In answer to "What effect does the patient's condition have on the family" Assessor #1 documented the wife reported, "It's deteriorated it, both extended and in house." In answer to "What effect does the family have on the patient's condition" Assessor #1 documented, "Pt reported that it was determined 3 months [ago] by wife that they would be married on paper only."

f. The "Chemical Dependency Assessment [CDA]" of the "Comprehensive/Psychological Assessment Tool - Part 2" revealed Assessor #1 documented:

Question #1- The Assessor documented "No" the patient did not have a current substance abuse diagnosis. The section for the "Physician who diagnosed the patient" was left blank.
There was no documentation the facility obtained the information from Hospital #2 or the patient's primary psychiatrist that would have revealed the patient did have a current substance abuse diagnosis.

Question #2- The Assessor documented "Yes" the patient was willing to come off of all addictive substances. In answer to "What is the patient's motivation to seek treatment today?" the patient reported, "Just want peace, I want peace again."

Question #3- The Assessor documented "Yes" in answer to "According to the patient, is substance abuse a major part of the problem?"

Question #4- The Assessor documented "Yes" in answer to "Is the patient free of psychosis or cognitive deficits and thus appropriate for a high functioning unit such as West [inpatient unit] or TRP [Total Recovery Program]?"

Question #5 a. - "How often do you have a drink containing alcohol?" with an answer of "4 or more times a week" scoring 4 points.

Question 5 b. - "How many drinks containing alcohol do you have on a typical day when you are drinking?" with an answer of "10 or more" scoring 4 points.

Question #5 c. - "How often do you have six or more drinks on one occasion?" with an answer of "Daily or almost daily" scoring 4 points. A "Total Score" of 12 was obtained based on Question #5.

The CDA section contained questions requiring a "Total Score" and revealed, "The score is based on a scale of 0-12...In men, a score of 4 or more is considered positive for identifying hazardous drinking or active alcohol use...IF ALL ANSWERS TO QUESTIONS 1, 2, 3, AND 4 ARE YES, PATIENT SHOULD BE admitted TO THE TOTAL RECOVERY PROGRAM."

g. Assessor #1 documented, "...Pt denies SI [suicidal ideation], HI [homicidal ideation], psychosis and withdrawal. Pt has bipolar and is very depressed and anxious..." The assessor documented the patient's symptoms, "do not meet criteria for emergent medical condition" and reviewed with the physician via telephone on 2/14/17 at 2:59 PM. There was no documentation the Intake Assessment information had been discussed with the Psychiatrist.

Assessor #1 documented the "Provisional Diagnosis" of Bipolar/Depressed-Severe and Alcohol use Disorder-Severe.

Review of the "RECOMMENDATIONS FOR SERVICES/REFUSALS OF TREATMENT" form dated 2/14/17 revealed Assessor #1 gave Patient #1 the name of 2 referrals, one to his previous Psychiatrist (Physician #4) and the other to Alcoholics Anonymous (AA) for the patient to obtain appointments himself. There was no documentation a physician had examined the patient, assessed the patient, diagnosed the patient or written discharge orders for the patient.

There was no documentation Assessor #1 informed the patient of the urgency level at which to see his psychiatrist or that the patient's concerns that his insurance would not cover inpatient treatment was addressed by staff.

The patient was discharged home with his wife on 2/14/17 at 2:39 PM without any treatment.

h. Review of the Police Report dated 2/19/17 at 3:55 AM revealed police were on the scene at the home of Patient #1. The report revealed that the patient and his wife were deceased .

In an interview on 3/29/18 at 10:15 AM in the Homicide Police conference room, the Homicide Sergeant verified Patient #1 and his wife were found deceased on [DATE]. The Sergeant stated Patient #1 shot his wife several times, killing her and then turned the gun on himself, killing himself.

i. In an interview on 3/28/18 at 10:20 AM in the conference room, RN #1 verified she performed the nursing part of the intake assessment for Patient #1. RN #1 stated the patient had come from his Orthopedic follow up appointment and was having problems with alcohol abuse. RN #1 stated it was her understanding that Patient #1 had detoxed at Hospital #2 (2/6/17 - 2/10/17), but had been drinking again, and was asking for pain medications. RN #1 stated that Patient #1 went to the Administration building upon arrival to Hospital #1's grounds, instead of the Assessment building. The patient and his wife got into a verbal altercation and the facility van came to take the patient to the Assessment building. There were tense emotions between the patient and his wife. RN #1 stated Patient #1 was rambling and angry. RN #1 stated the patient was angry that his insurance didn't provide better insurance and would not cover inpatient treatment. The patient's wife made statements that she was angry towards the patient about his behavior at home and that his drinking was ruining their home life. RN #1 stated nobody said why he wasn't admitted , but assumed it was because he didn't want a big bill, that's what he said.

In an interview on 3/28/18 at 11:04 AM in the conference room Assessor #1 (Master of Arts in Sociology) verified she performed the intake assessment for Patient #1. Assessor #1 stated the wife said she felt co-dependent. Assessor #1 stated after she completed her assessment, she called Physician #1 via phone and informed him that Patient #1 had detoxed in Hospital #2. Assessor #1 stated she was not told until after the patient left, that a Code Yellow had been called for Patient #1 and that his wife was afraid of him. Assessor #1 was asked, If she had been aware of the verbal altercation at the Administration building and that the wife was afraid of him, would she have assessed the patient differently. Assessor #1 stated, "I would have specifically asked the wife more questions if I had been made aware of the code situation and the wife voicing she was afraid of him."

In a telephone interview on 3/28/18 at 2:32 PM Physician #2 (Patient #1's Primary Care Physician) stated he was notified by Physician #3 (Patient #1's Orthopedist) that Patient #1 had been to Physician #3's office that morning and needed a behavioral hospital referral to Hospital #1 for alcohol treatment. The physician stated a referral was called in to Hospital #1 by his nurse.

In a telephone interview on 3/28/18 at 6:15 PM Physician #3 (Patient #1's Orthopedist) verified that he had seen Patient #1 in his office on 2/14/17. Physician #3 stated the patient was withdrawing from alcohol, was having marital problems with his wife and sleeping in separate areas of their home. Physician #3 stated after looking at the patient's situation, he notified Physician #2 (Patient #1's Primary Care Physician) of his concerns and the need for a referral to a behavioral hospital facility.

An interview was conducted with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Quality and Risk Manager on 3/29/18 at 12:20 PM regarding the Code Yellow called for Patient #1 on 2/14/17. The CEO stated there was no documentation of the Code Yellow and could not recall who was present for the code. The CNO stated Patient #1's "wife came in asking for directions [to the assessment area], she [wife] was visibly upset. [Name of Patient #1] was getting loud...She [Patient #1's wife] didn't want to get in the car with him [Patient #1]...We called a Code yellow..."

In a telephone interview on 3/29/18 4:35 PM Physician #1 (The on call psychiatrist at Hospital #1) verified that he had been contacted by telephone by Assessor #1 of the 2/14/17 regarding Patient #1. Physician #1 stated he was informed that Patient #1 had detoxed from alcohol at Hospital #2, had no Suicidal or Homicidal Ideations and did not want to be hospitalized . Physician #1 stated the patient did not meet involuntary admission criteria. Physician #1 was asked if he had been informed about his behavior when the Code Yellow was called or that his wife was afraid of him. Physician #1 stated, "I was not told."

In a telephone interview on 4/2/18 at 10:06 AM Physician #4 (Patient #1's outpatient Psychiatrist) stated the last time she had seen Patient #1 was 1/26/17. The physician stated the patient had a substance abuse problem with alcohol and needed a detox program.

In an interview of 4/2/18 at 12:45 PM in the conference room the Director of Admissions verified the Nurse and Assessor would conduct the intake assessment/examination and then call the on-call physician and give him a patient report over the telephone.

In an interview on 4/2/18 at 2:18 PM in the conference room the CEO stated the discharge papers that were sent home with Patient #1 would be the "Recommendations for Service/Refusal of Treatment" form. The CEO stated the top "Recommendations" section of the form was completed when "we don't think the patient meets inpatient qualifications and send this recommendation with the patient." The CEO stated the bottom section titled "Inpatient Treatment Refusal" is completed "If they refuse" inpatient treatment. The CEO stated refusal of inpatient treatment was not applicable for Patient #1 since he was not recommended for inpatient admission.

5. Medical record review revealed Patient #2 was a [AGE] year old who presented to Hospital #1's Intake Assessment Department on 9/4/17 at 11:15 AM with the chief complaint of " ...Anxiety ...Overdose on protonix ...one week ago ...Probable addiction to morphine and dilaudid due to stomach pain ...Has been in and out of hospital for past 3 months ...[started with] foot infection ...removed little toe and part of left foot ...been in hospital 6-8 times this month ...can't keep food or drink down ...hasn't slept in 3-4 days ...Last dilaudid and morphine was 5 days ago ...Use of pain meds ..."

Review of the Comprehensive/Psychosocial Assessment [CPA] Tool-Part 2" revealed Assessor #3 (a Licensed Clinical Social Worker) documented, "Extreme anxiety...Probable withdrawal from opioid pain medication..."

There was no documentation a physician assessed, examined or diagnosed the patient in Hospital #1's Intake Assessment Department.

Record review revealed Assessor #3 notified Physician #7 (the on call physician) via telephone on 9/4/17 at 4:15 PM of Assessor #3's assessment and the recommendations to admit the patient to Hospital #1's geriatric psychiatric unit were given over the telephone.

6. Medical record review revealed Assessor #4 (Bachelor Social Worker with a Registered Nursing degree) notified Physician #6 by telephone (the on call physician) of an assessment of Patient #3 on 6/6/17 at 7:44 PM. Recommendation were to admit the patient to Hospital #1's geriatric psychiatric unit.

The record revealed Patient #3 was a [AGE] year old who had not presented to Hospital #1's Intake Assessment Department until 9:50 PM on 6/6/17 via ambulance, 2 hours after the Assessor had already informed the on-call physician by telephone of an assessment of Patient #3.

The record revealed the chief presenting complaint was "Per daughter/POA [Power of Attorney] earlier today she found Pt [patient] outside his home wearing layers of soiled clothes with his pants down randomly knocking on neighbors' doors ...", and the patient had been transferred to Hospital #1 from a military hospital emergency room .

Review of the "Comprehensive/Psychosocial Assessment [CPA] Tool-Part 1" revealed Assessor #4 documented, "Pt [patient] has been having a gradual increase in confusion over the past 4 months...lives alone and daughter brings meds [medications] and meals daily but she is unsure how well Pt has been eating & taking meds when she is not around ..."

The "Mental Status" section of the CPA revealed Assessor #4 documented the patient was Oriented to person; speech was soft, random mumbling; Mood was flat; thought process and content was confused; and judgment, insight and memory was poor.

The 'Initial Evaluation of Risk to Self/Others" form revealed Assessor #4 documented, " ...Pt at Low/no risk for suicide/homicide but at imminent risk for vulnerability due to Pt's increased/excessive level
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review and interview, the facility failed to provide an appropriate transfer that was certified by a physician or Qualified Medical Personnel (QMP) for 1 of 1 (Patient #18) transfers from the Hospital #1's Intake Assessment Department.

The findings included:

1. Review of the facility "EMTALA [Emergency Medical Treatment And Labor Act] - Medical Screening Examination [MSE] and Stabilization" policy revealed, "...ESTABLISHING MEDICAL STABILIZATION The determination of whether an individual is stable is not based on the clinical outcome of the individual's medical condition. An individual is considered stable when...2. Stable for transfer. The physician or QMP [Qualified Medical Personnel] treating the individual in the DED [Dedicated Emergency Department] has determined within reasonable clinical confidence no material deterioration of the condition is likely, within reasonable medical probability...In the case of an individual with a psychiatric condition, the individual is protected and prevented from injuring himself/herself or others..."

2. Medical record review revealed Patient #18 was a [AGE] year old who presented to Hospital #1's Intake Assessment Department on 12/31/17 at 8:27 PM with the chief complaint of "...Active SI [suicidal ideations] [symbol for with] Plan to O/D [overdose] on whatever pills she can get her hands on. Pt [Patient] is severely depressed. Pt is also exhibiting feeling of wanting to harm others if only she feels they are a threat to her. Pt also extremely paranoid..."

Review of the "COMPREHENSIVE / PSYCHOSOCIAL ASSESSMENT" (CPA) Tool - Part 1 revealed Assessor #17 (a Masters in Social Work) documented, "...on 11-13-17 a man approached her assisted living complex claiming to need help...he threatened her with a knife ...Pt has always battled depression But things have been worse since then. Pt attempted to O/D [overdose] on 12-28-17...Pt's sister states Pt will take any pill she can get her hands on ..."

Review of the Medical Screening Form revealed on 12/31/17 at 9:15 PM Registered Nurse (RN) #3 documented the patient's blood pressure was 193/90 and the patient complained of chest pain. RN #3 documented Physician #13 (on call Internal Medicine Physician) was notified via telephone and an order was given to transport Patient #18 to Hospital #3's DED.

Review of the "Mode Of Transfer Transfer Authorization" form dated 12/31/17 at 9:36 PM documented the following:

The "Medical Condition Identified" section revealed RN #3 identified via check mark, "Patient screened, but no emergency medical condition [EMC] was identified."
There was no documentation a physician examined or assessed the patient in the Intake Assessment Department at Hospital #1 prior to the transfer.

The "Stabilization" section revealed RN #3 identified via check mark, "Stabilization established-The patient's emergency medical condition has been treated such that, within reasonable medical probability, no material deterioration of the condition is likely to result from or occur during the transfer of the individual..."
There was no documentation a physician had examined the patient to determine if the patient was stabilized for transfer.

The "Risks and Benefits of Transfer" section revealed, "All transfers have the risks of traffic delays, accidents during transport, pain and discomfort on movement, and the limitations of equipment and personnel in the vehicle, all of which could endanger the health, medical safety, and survival of the patient." RN #3 identified via check mark, "Higher level of Care."

The "Examination and Treatment" section revealed RN #3 identified via check mark, "Medical screening examination (MSE) performed to the extent possible considering the emergency departments capabilities and ancillary services and/or on-call physicians available to determine if the patient has an emergency medical condition..."
There was no documentation a QMP or physician had performed a MSE prior to the transfer.

The "Interaction with Accepting Facility" section revealed RN #3 indicated via check mark, "Transfer accepted by receiving hospital" and documented the hospital was Hospital #3. RN #3 documented the transferring physician from Hospital #1 was Physician #13 (on call Internal Medicine Physician).
There was no documentation a physician or QMP examined the patient to make a determination of the need for a transfer or had communicated with and determined there was an accepting physician at Hospital #3's DED.