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.

CRESTWYN BEHAVIORAL HEALTH 9485 CRESTWYN HILLS COVE MEMPHIS, TN 38125 Oct. 11, 2018
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on medical record review and interview, the facility failed to ensure the central intake log included accurate information on each individual seeking care for an emergency medical condition for 1 of 20 (Patients #1) sampled patients presenting to the Intake Assessment Department seeking care.

The findings included:

1. Review of the central "Intake log" revealed Patient #1, a 16 year old, presented to the hospital's (Hospital #1) Intake Assessment Department (also known as their hospital emergency department area) on 8/17/18 at 0750 via ambulance. The log revealed the patient had an "Emergency Psychiatric Emergency Condition" and was "admitted " to the hospital at 11:00 AM.

Review of the Inquiry Worksheet dated 8/17/18 at 12:00 PM revealed, "Upon review [name of Hospital] is not in network [with name of insurance] for Adolescent pts [patients]." The patient was discharged home with his father.

In an interview on 10/9/18 at 2:00 PM in the group activity room, the Director of Intake verified the patient was discharged home and was not admitted to the hospital.

The central intake log failed to reflect the accurate information that the patient was discharged with a parent.
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 hospital's Intake Assessment Department (also known as their hospital emergency department area) with an emergency medical condition (EMC) received an adequate assessment to determine necessary stabilizing treatment for 9 of 20 (Patients #1, 2, 5, 7, 8, 10, 12, 14 and 16) sampled patients and all patients received an appropriate transfer for 1 of 1 (Patient #5) sampled patient.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policies, Medical Staff Bylaws, medical record review, observation and interview, the hospital (Hospital #1) failed to ensure an adequate assessment was performed to determine the necessary treatment to stabilize signs/symptoms of psychiatric conditions for 9 of 20 (Patients #1, 2, 5, 7, 8, 10, 12, 14 and 16) sampled patients with an emergency medical condition (EMC).

The findings included:

1. Review of the facility "EMTALA [Emergency Medical Treatment And Labor Act] COMPLIANCE" policy, effective date 10/5/18, revealed, "...Any person who presents to the Hospital will be evaluated to determine whether the person has an emergency medical condition. If so, the patient must be stabilized, and/or appropriately transferred...Psychiatric Emergency...the law requires that persons must be...a danger to self, a danger to others, or gravely disabled...Examples of Psychiatric Emergency Medical Conditions are the following...Depression with feelings of suicidal hopelessness...Delusions, severe insomnia, and hopelessness...History of recent suicide attempt or suicidal ideation...History of recent assaultive, self-mutilation or destructive behavior...The attending physician and/or on-call physician is responsible for the supervision, evaluation and stabilization of his/her patient when he/she is on the hospital grounds and available...In the absence of a physician, a nurse practitioner...may conduct medical screening examinations..."

Review of the "Suicide Risk Assessment" policy revealed, "...Staff is to identify patients at risk for suicide. Suicide risk assessments are completed for all patients and include specific factors and features that may increase or decrease risk for suicide...Procedure...The admitting staff will complete the initial Suicide Risk Assessment (SRA form) during the initial admission intake process...The treatment team is advised of any relevant information gained from a suicide risk assessment that may compromise patient safety...The treatment team, in collaboration with the patient, will develop the treatment plan as indicated from the assessment of suicide risk...If any suicide risk assessment renders information that has potential to immediately affect patient safety and/or results in a score Medium, High or Severe, the unit nurse/nurse supervisor and practitioner shall be notified immediately. This applies to the initial and all subsequent suicide risk assessments. The practitioner shall order the appropriate level of observation based on results of the suicide risk assessment and additional patient specific information...Documentation of consult and subsequent physician orders are noted in the patient chart..."

Review of the "Admission Process" policy, in effect on 8/17/18, revealed, "...Any person who presents requesting a psychiatric service assessment will be assessed. The assessment will be completed by a Registered Nurse or Mental Health Professional...The Admissions Department receives referral information regarding the potential patient and obtains the necessary pre-admission information, conducts a clinical overview, verifies insurance, and arranges a screening/admitted and time...After the arrival of the potential patient, the individual will work with an Intake Specialist...The Intake Specialist must then complete an Admission Screening...which will include preliminary information on possible substance abuse, psychotic symptoms, and suicidal risk..."

Review of the Medical Staff Bylaws revealed, "...GENERAL OBLIGATIONS OF MEDICAL STAFF MEMBERSHIP...obligates himself to...abide by all applicable federal and state laws, rules, and regulations..."

2. Review of Hospital #1's "Inquiry Worksheet" form revealed Hospital #2 called Hospital #1 on 8/17/18 at 3:11 AM requesting to transfer Patient #1 to Hospital #1. The form revealed, "...Transported to [name of Hospital #2] by police. Ran away 3 times this week...Patient stated that he planning to commit suicide and that it will be quick and he won't be depressed anymore...plan to overdose...he is adopted..." The form revealed the patient had insurance.

Medical record review revealed Patient #1 arrived to Hospital #1 on 8/17/18 at 7:50 AM via ambulance due to a lack of inpatient beds at Hospital #2.

Review of the "Intake Assessment [IA]" form dated 8/17/18 at 8:30 AM revealed Intake Coordinator (IC) #3 documented, "...Patient [Patient #1] is guarded, minimally responsive, minimizing his behaviors/symptoms. Struggling in school [and with] his parents...Pt uses SI as a coping mechanism."

The IC documented the patient's Suicide Risk Factor as high with a score of 42, with high being 42-58.

Under the section on the form titled, "Notifications/Actions If Medium, High or Severe Risk" revealed the IC documented the Nurse Supervisor was notified on 8/17/18 at 9:40 AM.

Under the "Suicide Precaution Ordered" section and the "Observations" section of the form was blank and not completed. There was no documentation a patient specific safety plan was developed to provide stabilizing treatment for the patient's emergency psychiatric condition in the Intake Assessment Department.

The physician was notified at 9:31 AM and the recommendation was made to admit to "Acute Inpatient" related to "Potential danger to self or others...Meets criteria for dual diagnosis..."

Review of the "Inquiry Worksheet" form dated 8/17/18 at 12:00 PM revealed an addendum note, "...Upon review [name of Hospital #1] is not in network [with name of Insurance] for Adolescent pts...Pt is not presently suicidal...Father wants to take pt home [with a] referral. Pt [and] father signed a no-Harm contract. Referred to [name of 2 psychiatric services]." The patient's father signed the no-harm contract form. There was no documentation the patient signed the no-harm contract.

Review of the "No Harm Contract" revealed, "I, [name of Patient #1], hereby agree that I will not harm myself in any manner, attempt suicide, or harm anyone else..." The form listed the emergency contacts of 911, Police Department Crisis Team, Mobile Crisis and the 24 hour suicide prevention line.

Review of the "Post-Assessment Referral/Refusal of Treatment" form revealed Patient #1 was assessed at the hospital, "...and did not meet criteria for inpatient or partial hospitalization ..." The section titled "The reason for refusal of treatment" was blank and not completed. The form revealed, "...The benefits of treatments and the potential risks of not being treated have been explained to me...In the event that symptoms worsen...I agree to call 911, or go to the closest emergency room , or come back to [name of Hospital #1]..." The form listed the 2 psychiatric services and to call insurance company for a referral.

There was no documentation of an assessment, evaluation or medical screening examination (MSE) to determine that the patient was no longer suicidal and that the EMC no longer existed.
There was no documentation the patient was offered a transfer to another facility to treat the patient's psychiatric emergency medical condition.

In an interview on 10/8/18 at 1:40 PM in the group therapy room, the Director of Intake (DOI) stated during the registration process, payor information may be obtained prior to the MSE or intake assessment.

In an interview on 10/8/18 at 2:45 PM in the group therapy room, the Risk Manager (RM) verified she had provided all records for Patient #1.

In an interview on 10/9/18 at 10:45 AM in the group therapy room, IC #3 stated "We admitted the patient [Patient #1] and got him to the unit [inpatient unit]. Found out were were not in network with [name of insurance] for adolescents. He was referred [to outside resources], signed a no harm contract and referred...Father didn't want to stay..." IC #3 stated the psychiatrist was notified.

In a telephone interview on 10/9/18 at 1:10 PM the psychiatrist stated he did not remember this patient because it had been a while. The psychiatrist stated, "...I don't care if they have insurance or not, we see them and treat them. They don't look at whether they have insurance..." The psychiatrist stated he did not know what was documented about the patient leaving.

In a telephone interview on 10/9/18 at 1:30 PM, Patient #1's mother stated the father and patient left because the insurance didn't pay for adolescents, "they didn't refuse services..."

In an interview on 10/9/18 at 2:00 PM in the group therapy room, the DOI stated the patient's father signed a post-assessment referral refusal of treatment that listed the risks and benefits.

In a telephone interview on 10/10/18 at 8:20 AM, Patient #1's father stated, the police took his son to Hospital #2 and they did not have any beds, so they transferred him to Hospital #1. The father stated, someone from the business office, at Hospital #1, came and told me they do not take my insurance for adolescent care. The father stated Hospital #1 did not provide treatment or offer them a transfer to a facility for inpatient treatment. The father stated it took a while to find some where that could provide treatment for Patient #1. The father stated Patient #1 was now in week 4 of a 7 week treatment program.

There was no documentation necessary stabilizing treatment was provided for Patient #1 prior to his discharge home with his parent.

3. Review of Hospital #1's "Inquiry Worksheet" form revealed Hospital #4 called Hospital #1 on 10/8/18 at 3:20 AM requesting to transfer Patient #2 to Hospital #1. The form revealed Patient #2 presented to Hospital #4 after she took 15 pills, "..in an attempt to kill herself. Tired of living. Been depressed. Raped in July..." The form revealed the patient had insurance.

Medical record review revealed Patient #2 was [AGE] years old and presented to Hospital #1 on 10/8/18 at 8:46 AM via ambulance as a transfer from Hospital #4.

Review of the medical screening examination (MSE) dated 10/8/18 at 8:00 AM, before the patient arrived at 8:46 AM, revealed Family Nurse Practitioner (FNP) #2 documented the patient was "Cooperative...Alert... Oriented... Lethargic...tearful..." FNP #2 documented, "...Patient meets criteria for Emergent Medical Condition based on risk of imminent harm to self/others due to psych. conditions...Meets criteria for admission. Pt deemed medically clear." There was no documentation a plan was developed to provide stabilizing treatment to address the risk of imminent harm to self and/or others while the patient was in the Intake Assessment Department.

Review of the IA dated 10/8/18 at 9:50 AM revealed IC #3 documented, "...Pt had an intentional overdose...on 10/7/18. Hx of Depression, smokes THC [Tetrahydrocannabinol] daily to cope. Pt was raped in July 18 [and] also reports grief issues [and] being a single mom as her main stressors...couldn't take it anymore..."

The IC documented the patient's Suicide Risk Factor score was high at 50, with high being 42-58. The "Notifications/Actions If Medium, High or Severe Risk" section revealed the IC documented FNP #2 was notified on 10/8/18 at 10:55 AM, 2 hours after the patient arrived.

Under the sections titled "Suicide Precaution Ordered" and "Observations" it was blank and not completed. There was no documentation an appropriate level of observational treatment was ordered based on the SRA in accordance with the facility policy to keep the patient and/or others safe.

In an interview on 10/11/18 at 10:25 AM in the group therapy room, the DOI stated she believed the MSE time had been incorrectly documented, and should have been 9:00 AM, instead of 8:00 AM. The DOI verified the patient left the Intake Assessment Department and admitted to the hospital's inpatient unit at 12:04 PM.

There was no documentation appropriate stabilizing treatment for the patient's emergency psychiatric condition was provided in the Intake Assessment Department.

4. Medical record review revealed Patient #5 was [AGE] years old and (MDS) dated [DATE] at 4:18 PM via car and reported issues with alcoholism and suicidal thoughts.

Review of the "Intake Questionnaire" form completed by the patient revealed the patient reported she couldn't sleep, wakes up bruised; anxiety, paranoia; drinking at work and lost her job, wanting to die and hurt self as punishment; impossible to focus; impulsiveness and risky activity; voice that tells me I'm worthless; feelings of wanting to harm self; past and current suicidal thoughts and getting my affairs in order so she could go in peace.

Review of the MSE revealed on 10/9/18 at 1640 (4:40 PM) Family Nurse Practitioner (FNP) #2 documented, "...Assessment Findings...Patient meets criteria for Emergent Medical Condition based on risk of imminent harm to self/others due to psych. [psychiatric] conditions..." The FNP documented the patient had "...wounds, healing scabs...Large bruise (self harm) [to the right forearm]...former patient...I have deemed this patient medically clear for admission..."

Review of the IA revealed on 10/9/18 at 1920 (7:20 PM) IC #1 documented the Suicide Risk Assessment score to be 44 (high risk 42-58). The IC notified the physician at 8:05 PM and was recommended for "Acute Inpatient" admission related to "Acute psychiatric condition requires 24 hour skilled nursing/medical oversight...potential danger to self or others...Less-intensive treatment not safe or feasible..."

Under the section titled "Notifications/Actions If Medium, High or Severe Risk" revealed the IC documented the psychiatrist was notified on 10/9/18 at 8:05 PM of the high suicide risk assessment.

Under the sections titled "Suicide Precaution Ordered" and "Observations" it was blank and not completed.

The patient remained in the Intake Assessment area form 10/9/18 at 4:18 M until 10/10/18 at 3:30 PM. There was no documentation a plan was developed to provide stabilizing treatment to address the patient requiring 24 hour oversight, the potential danger to self or others and the high suicide risk assessment while the patient was in the Intake Assessment Department.

In an interview on 10/10/18 at 3:30 PM in the group therapy room the DOI stated the hospital had no available beds to admit the patient, there were no surrounding hospitals with an available bed and a mobile crisis unit was called to assist with finding a bed.

In an interview on 10/11/18 at 11:00 AM in the group therapy room the DOI stated the patient left via ambulance and transported to an out of state hospital on [DATE] at 1:13 AM. The DOI verified the entire patient's record had been provided.

There was no documentation the routine standard every 15 minute checks were conducted on this patient. There was no documentation a patient specific safety plan was developed to provide stabilizing treatment for the patient's emergency psychiatric condition while in the Intake Assessment Department.

5. Review of Hospital #1's "Inquiry Worksheet" referral form revealed Hospital #6 referred Patient #7 to be transferred to Hospital #1 on 10/8/18 at 3:20 AM. The form revealed the intake assistant documented, "...SI with plan...In [emergency room at Hospital #6 name] patient wrapped power cord around her neck...feels like family would be better off without her. Has a rope hidden in garden to hang self..." Patient #7 had presented to Hospital #6 on 10/8/18 at 8:19 PM with Suicidal Ideation. Hospital #6 had documented, "...patient had hands around her neck, trying to choke herself..." The form revealed the patient had insurance.

Medical record review revealed Patient #7 was [AGE] years old presented to Hospital #1's Intake Assessment Department on 10/9/18 at 3:50 PM via police department with Suicidal Ideations.

Review of the MSE revealed on 10/9/18 at 3:55 PM FNP #2 documented, "...Patient meets criteria for Emergent Condition based on risk of imminent harm to self/others due to psych. conditions...."

Review of the IA revealed on 10/9/18 at 5:48 PM IC #2 documented the Suicide Risk Assessment score to be high risk at 52, with the high range being 42-58. Under the section titled "Notifications/Actions If Medium, High or Severe Risk" the IC documented the Nurse Supervisor was notified at 6:03 PM.

The physician was notified at 1:42 AM on 10/9/18 of the high suicide risk assessment, which was prior to the patient arriving to Hospital #1. The IC documented the physician ordered for "Acute Inpatient" admission related to "Acute psychiatric condition requires 24 hour skilled nursing/medical oversight...potential danger to self or others..."

Under the sections titled "Suicide Precaution Ordered" and "Observations" it was blank and not completed.

There was no documentation a plan was developed to provide stabilizing treatment to address the high risk suicide assessment, requiring 24 hour oversight and potential danger to self or others while the patient was in the Intake Assessment Department.
There was no documentation the every 15 minute checks were performed at 4:15 PM, 4:30 PM, 4:45 PM and 5:00 PM prior to the patient leaving the Intake Assessmemt area on 10.10.18 at 7:39 PM.

6. Review of Hospital #1's "Inquiry Worksheet" referral form revealed Hospital #7 called a referral for transfer of Patient #8 to Hospital #1 on 10/9/18 at 8:49 AM. The form revealed, "...HI [Homicidal Ideations] towards his mother...He took a pair of scissors [and] threatened to stab his mother...Aggressive...They are living in a domestic living type shelter...Hx of sexual trauma [and] domestic abuse...Developmental delays [Autism]..." The form revealed the patient had insurance.

Review of the IA note revealed IC #2 notified the physician at 9:09 AM, before the patient arrived, and recommendations were given for "Acute Inpatient" admission related to "Potential danger to self or others..."

Medical record review revealed Patient #8 was [AGE] years old who presented to Hospital #1's Intake Assessment Department on 10/9/18 at 11:52 AM from Hospital #7 via private owned vehicle with his mother.

Review of the MSE revealed on 10/9/18 at 12:12 PM FNP #2 documented, "...Patient meets criteria for Emergent Medical Condition based on physical finding...Patient meets criteria for Emergent Condition based on risk of imminent harm to self/others due to psych. conditions...."

Review of the IA revealed on 10/9/18 at 1:00 PM IC #2 documented the Suicide Risk Assessment score to be medium risk at 27, with the medium range being 25-41. T

Under the section titled "Notifications/Actions If Medium, High or Severe Risk" the IC documented the FNP was notified at 1:30 PM.

Under the sections titled "Suicide Precaution Ordered" and "Observations" it was blank and not completed.

The IA revealed the patient had "active homicidal/violent thoughts toward others...active homicidal/violent behaviors toward others...hostility/aggression-bullies, threatens, intimidates...past violent/assaultive behaviors toward others..." There was no documentation a plan was developed to provide stabilizing treatment to address the medium suicide risk assessment or the active homicidal/violent thoughts towards others while the patient was in the Intake Assessment Department.

The patient left the Intake Assessment Department and was admitted on [DATE] at 3:24 PM.

7. Review of Hospital #1's "Inquiry Worksheet" referral form revealed Hospital #9 called to transfer of Patient #10 to Hospital #1 on 10/5/18 at 5:05 PM. The form revealed, "...Last night pt took Prozac [and] Benadryl in an OD attempt (10 - 15 Prozac and whole package of Benadryl)..." The form revealed the patient had insurance.

Record review revealed Patient #10 was transported from Hospital #9 via police department. The patient arrived at Hospital #1 on 10/6/18 at 11:30 AM.

Review of the MSE revealed on 10/6/18 at 12:11 PM FNP #1 documented, "...Patient meets criteria for Emergent Medical Condition based on risk of imminent harm to self/others due to psych. conditions...."

Review of the IA revealed on 10/6/18 at 12:30 PM IC #7 documented the Suicide Risk Assessment score to be medium risk at 29, with the medium range being 25-41.

Under the section titled "Notifications/Actions If Medium, High or Severe Risk" the IC documented the physician was notified on 10/5/18 at 5:21 PM. before the patient's arrival and ordered acute inpatient related to "Potential danger to self or others"

The nurse supervisor was also notified on 10/5/18 at 5:43 PM, before the patient arrived to Hospital #1.

Review of the "Observations-Intake" form dated 10/6/18 for Patient #10 revealed no documentation the routine standard every 15 were performed from 11:45 PM - 1:27 PM, before the patient left the Intake Assessment Department.

There was no documentation of a plan revealing the every 15 minute checks were sufficient to provide stabilizing treatment while the patient was in the Intake Assessment Department. There was no documentation a plan was developed to provide stabilizing treatment to address the medium suicide risk assessment or the potential danger to self or others while the patient was in the Intake Assessment Department.

The patient left the Intake Assessment Department and was admitted on [DATE] at 1:27 PM.

In an interview on 10/11/18 at 1:30 PM , in the group therapy room, the DOI verified the every 15 minute routine standard safety checks had not been completed.

8. Review of Hospital #1's "Inquiry Worksheet" referral form revealed Hospital #2 called to transfer of Patient #12 to Hospital #1 on 10/6/18 at 5:52 PM. The form revealed the patient was [AGE] years old and on 10/5/18 the patient took cough and cold medication and alcohol in a suicide attempt. The patient is paranoid and hears voices. The form revealed the patient had insurance.

Record review revealed Patient #12 was transported from Hospital #2 via ambulance. The patient arrived at Hospital #1 on 10/6/18 at 7:43 PM.

Review of the MSE revealed on 10/6/18 at 7:58 PM FNP #1 documented, "...Patient meets criteria for Emergent Medical Condition based on risk of imminent harm to self/others due to psych. conditions...."

Review of the IA revealed on 10/6/18 at 8:13 PM IC #6 documented the Suicide Risk Assessment score to be high risk at 44, with the high range being 42-58.

Under the section titled "Notifications/Actions If Medium, High or Severe Risk" the IC documented the physician was notified on 10/6/18 at 6:09 PM and the nurse supervisor was notified on 10/6/18 at 6:15 PM, before the patient arrived to Hospital #1. The physician recommended to admit the patient to acute inpatient related to "Acute psychiatric condition requires 24 hour skilled nursing/medical oversight...Potential danger to self or others...Less-intensive treatment not safe or feasible...Meets criteria for dual diagnosis..."

Review of the "Observations-Intake" form dated 10/6/18 for Patient #12 revealed the routine standard every 15 minute checks were not performed after 8:15 PM until the patient left the Intake Assessment Department at 9:40 PM and was admitted to the inpatient unit.

There was no documentation a plan was developed to provide stabilizing treatment to address the high suicide risk assessment, requiring 24 hour oversight and the potential danger to self or others while the patient was in the Intake Assessment Department.

In an interview on 10/11/18 at 11:45 AM, in the group therapy room, the DOI verified the every 15 minute routine standard safety checks had not been completed.

9. Medical record review revealed Patient #14 was [AGE] years old, (MDS) dated [DATE] at 7:10 PM via car with thoughts of hurting herself.

Review of the MSE revealed on 10/7/18 at 7:29 PM FNP #1 documented, "...Pt reports currently having active thoughts of suicide...Patient meets criteria for Emergent Medical Condition based risk of imminent harm to self/others due to psych. conditions...."

Review of the IA revealed on 10/7/18 at 7:58 PM IC #6 documented the Suicide Risk Assessment score to be medium risk at 37, with the medium range being 25-41.

Under the section titled "Notifications/Actions If Medium, High or Severe Risk" the IC documented the RN Supervisor was notified at 8:40 PM and the physician was notified at 8:39 PM. The physician recommended to admit the patient to "Acute Inpatient" admission related to "Acute psychiatric condition requires 24 hour skilled nursing/medical oversight...potential danger to self or others...Failure of less-intensive treatment...Less-intensive treatment not safe or feasible."

Under the sections titled "Suicide Precaution Ordered" and "Observations" it was blank and not completed.

Review of the "Observations-Intake" for Patient #14 revealed the routine standard every 15 minute checks had been documented from 7:10 PM - 9:30 PM on 10/7/18. There was no documentation a plan was developed reflecting that the every 15 minute checks was sufficient to provide safe stabilizing treatment for the patient in the Intake Assessment Department. There was no documentation a plan was developed to provide stabilizing treatment to address the medium suicide risk assessment, requiring 24 hour oversight and the potential danger to self or others while the patient was in the Intake Assessment Department.

The patient left the Intake Assessment Department and was admitted on [DATE] at 9:48 PM.

10. Medical record review of Hospital #1's "Inquiry Worksheet" form revealed Hospital #8 called a referral for transfer Patient #16 to Hospital #1 on 10/9/18 at 2:35 PM. The form revealed Patient #16 had presented to Hospital #8's ED with Suicidal Ideations with the plan to inject air into his veins, reports auditory and visual hallucinations in last 2 weeks. The inquiry revealed the patient had insurance. Hospital #8's medical record revealed, "...Pt is a 15 yo male presenting with suicidal ideation with recent hx [history] of suicide attempt by overdosing...Pt recently moved in with father (2 weeks ago) and reports being bullied in school due to sexuality and gender identity...to be admitted to an adolescent facility..." Hospital #8's record revealed, "...states he [Patient #6] was at school today [10/9/18] and a classmate made a statement 'I think I found your boyfriend faggot'..." Patient #14 reported his mom told him "I wouldn't care if you committed suicide, go ahead and leave I don't care..." The patient had a friend that committed suicide last year.

Medical record review revealed Patient #16 was [AGE] years old, presented to Hospital #1's Intake Assessment Department on 10/9/18 at 8:30 PM via ambulance.

The IC documented the physician was notified on 10/9/18 at 2:37 PM, before the patient arrived and the recommendation was made to admit the patient to "Acute Inpatient" admission related to "Acute psychiatric condition requires 24 hour skilled nursing/medical oversight... potential danger to self or others..."

Review of the MSE revealed on 10/9/18 at 7:29 PM FNP #1 documented (prior to the patient's arrival), "...Pt reports currently having active thoughts of suicide...Patient meets criteria for Emergent Medical Condition based risk of imminent harm to self/others due to psych. conditions...."

Review of the IA revealed on 10/9/18 at 10:25 PM IC #3 documented the Suicide Risk Assessment score to be high risk at 55, with the high range being 42-58.

Under the section titled "Notifications/Actions If Medium, High or Severe Risk" the IC documented the RN Supervisor was notified at 11:05 PM and the FNP was notified at 8:51 PM.

Under the sections titled "Suicide Precaution Ordered" and "Observations" it was blank and not completed.

Review of the "Observations-Intake" form for Patient #16 revealed the routine standard every 15 minute checks had been performed on 10/9/18 from 8:30 PM - 11:39 PM. There was no documentation a plan was developed reflecting the routine standard every 15 minutes would be sufficient to provide safe stabilizing treatment while the patient was in the Intake Assessment Department.

The patient left the Intake Assessment Department and was admitted on [DATE] at 3:24 PM.

11. In an interview on 10/11/18 at 10:25 AM in the group therapy room, the RM and DOI were interviewed. The DOI stated it is routine and standard to conduct every 15 minute checks on all patients, there are cameras in the intake rooms and hallways and they are monitored "Fairly continuously." The DOI stated the suicide risk assessments are reviewed with the practitioner and a plan is determined and documented.
The surveyor asked if there was someone specifically assigned to watch the monitors. The RM stated, "No." The DOI stated, "All are supposed to check."

An interview was conducted with the DOI, RM and Division President (DP) on 10/11/18 at 1:30 PM in the group therapy room. The surveyor asked what stabilizing treatment was provided in the Intake Assessment Department for a patient that is suicidal and/or had a psychiatric EMC. The DP stated, "The stabilizing treatment would be, to keep them safe."
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical staff bylaws and rules and regulations, facility policy, medical record review and interview, the hospital failed to ensure patients presenting to the Intake Assessment Department (also known as their Emergency Department area) with a psychiatric emergency conditions were appropriately transferred to an accepting psychiatric hospital with the capacity and capability to treat the patient. The hospital failed to ensure the risks and benefits of transfer and all transfers were certified by qualified personnel for 1 of 1 (Patient #5) sampled patient that was transferred.

The findings included:

1. Review of the facility "EMTALA [Emergency Treatment And Labor Act] COMPLIANCE" policy revealed, "...It is the policy of the Hospital to assess, stabilize and or transfer persons who present with an emergency medical condition...Psychiatric Emergency the law requires that persons must be, as a result of a mental disorder, a danger to self, a danger to others, or gravely disabled...
A physician will sign a certification that based upon the information available at the time of transfer; the medical benefits...outweigh the increased risks to the individual...
Transfer...Before the hospital may transfer an individual, the hospital must satisfy the following conditions...
Risks Minimized...has provided the medical treatment within its capacity which minimizes the risks to the individual's health...
Receiving Physician...notified a physician at the receiving facility and has obtained the physician's consent to the transfer and confirmation that the individual meets the facility's admissions criteria relating to appropriate bed, personnel and equipment necessary to treat the individual...
Receiving Facility...has available space and qualified personnel for the treatment of the individual and has agreed to accept transfer of the individual and to provide appropriate medical treatment...
Accompanying Records and Documentation...A transfer summary signed by the physician and or qualified medical person..."

Review of the "Patient Transfer" policy revealed, "...[Name of Hospital] arranges for an appropriate transfer by...contacting a receiving facility that agrees to accept the patient, has space and qualified personnel available to provide the necessary treatment...The risks and benefits of the transfer should be explained to the patient...and should be documented on the PATIENT TRANSFER CONSENT form...the physician shall decide...what mode of transportation will be used to transfer the patient...The TRANSFER FORM and PATIENT TRANSFER CONSENT will also accompany the patient...the risks and benefits of the transfer should be explained...and be documented on the PATIENT TRANSFER CONSENT form...The TRANSFER FORM and PATIENT TRANSFER CONSENT will be completed..."

2. Review of the Medical Staff Bylaws revealed, "...GENERAL OBLIGATIONS OF MEDICAL STAFF MEMBERSHIP...obligates himself to...abide by all applicable federal and state laws, rules, and regulations..."

Review of the Medical Staff Rules and Regulations revealed, "...EMERGENCY MEDICAL CARE...The decision to transfer a patient in the event of a medical emergency is the responsibility of the practitioner...Emergency transfers shall be in accordance with the Hospital's EMTALA policies and procedures...All Medical Staff Members and AHP [Allied Health Professional] Staff Members must abide by EMTALA and by all applicable rules and regulations of CMS implementing EMTALA, as reflected in Hospital's EMTALA policies and procedures..."

3. Medical record review revealed Patient #5 was [AGE] years old and (MDS) dated [DATE] at 4:18 PM via car and reported issues with alcoholism and suicidal thoughts.

Review of the "Intake Questionnaire" completed by the patient, revealed the patient reported she couldn't sleep, wakes up bruised, anxiety, paranoia, drinking at work and lost her job, wanting to die and hurt self as punishment, impossible to focus, impulsiveness and risky activity, voice that tells her that she is worthless, feelings of wanting to harm herself, past and current suicidal thoughts and getting her affairs in order so she could go in peace.

Review of the Medical Screening Examination (MSE) revealed on 10/9/18 at 4:40 PM Family Nurse Practitioner (FNP) #2 documented, "...Assessment Findings...Patient meets criteria for Emergent Medical Condition based on risk of imminent harm to self/others due to psych. [psychiatric] conditions..." The FNP documented the patient had "...wounds, healing scabs...Large bruise (self harm) [to the right forearm]...former patient...I have deemed this patient medically clear for admission..."

Review of the Intake Assessment (IA) revealed on 10/9/18 at 7:20 PM Intake Coordinator (IC) #2 documented the Suicide Risk Assessment score to be high at 44, high risk 42-58. The IC notified the physician at 2005 (8:05 PM) and was recommended for "Acute Inpatient" admission related to "Acute psychiatric condition requires 24 hour skilled nursing/medical oversight...potential danger to self or others...Less-intensive treatment not safe or feasible..."

Review of the "Inquiry Worksheet" dated 10/9/18 at 8:05 PM revealed the hospital had no beds available to admit the patient. Three (3) other local hospitals were notified and also had no beds available. At 11:25 PM the worksheet revealed the hospital notified a mobile crisis company to assess the patient and assist with bed placement.

Review of the mobile crisis "Crisis Assessment" form dated 10/9/18 at 11:21 PM revealed the patient was "Referred to other: Private Hospital."

Review of the central "Intake Log" revealed the patient was "Referred to [name of a hospital in another state]" and departed on 10/10/18 at 1:13 AM via ambulance.

There was no documentation the practitioner ensured the receiving hospital had the capability and capacity to treat the patient, ensured there was an accepting physician, the risks/benefits were explained to the patient and designated the appropriate mode of transfer.

In an interview on 10/10/18 at 3:30 PM in the group therapy room, the Director of Intake (DOI) stated the hospital had no available beds to admit the patient, there were no surrounding hospitals with an available bed and a mobile crisis unit was called to assist with finding a bed.

In an interview on 10/11/18 at 11:00 AM in the group therapy room, the DOI confirmed there was no documentation the "Transfer Form" or "Patient Transfer Consent" form was completed for this patient. The DOI stated the patient left via ambulance and transported to an out of state hospital on [DATE] at 1:13 AM.