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.

DELTA SPECIALTY HOSPITAL 3000 GETWELL RD MEMPHIS, TN 38118 June 25, 2019
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on the hospital's Emergency Medical Treatment and Labor Act (EMTALA) policies, medical record review, and interview, the hospital failed to ensure all patients presenting to the hospital's psychiatric Intake Assessment Department (IAD) or Emergency Department (ED) seeking treatment received an appropriate Medical Screening Exam (MSE), patients with an emergency psychiatric medical condition received stabilizing treatment, patients were transferred appropriately, uninsured patients were not unduly discouraged from receiving a MSE and patients were informed of the risks for refusal of further screening for 7 of 22 (Patients #1, 13, 16, 19, 20, 21 and 22) sampled patients.

Refer to the findings in deficiencies A2406, A2407, A2408 and A2409.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy review, medical record review and interview, the hospital (Hospital #1) failed to maintain a central log that included accurate information on each individual who comes to the emergency room seeking treatment for 1 of 22 (Patient #1) sampled patients presenting to the hospital's psychiatric Intake Assessment Department (IAD).

The findings included:

1. Review of the facility EMTALA (Emergency Medical Treatment And Labor Act) policy revealed, "...A Central Log must be kept regarding all EMTALA transfers..."

2. Medical record review revealed Patient #1 was a [AGE] year old female and had diagnoses that included Schizophrenia, Bipolar, and Anxiety. The medical record documented the patient was homeless.

Review of EMTALA log maintained by the psychiatric IAD revealed Patient #1 presented via car to the psychiatric IAD on 6/13/19 at 1:33 PM with the chief complaint of "Psych" and homicidal ideations, and had an "Emergency Psychiatric Medical Condition."

The central log revealed on 6/15/19 at 6:00 AM the patient was a "transfer" to another facility.

In an interview on 6/18/19 at 4:45 PM in the conference room, the Director of Intake Admissions stated Patient #1 was discharged from the hospital and not transferred to another facility.

There was no documentation on the the hospital's psychiatric IAD central log of the disposition of the homeless patient.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record reviews, medical staff bylaws rules and regulations, ED log review, State Health Related Board Statutes, Policy and procedure review and interviews, the facility failed to ensure all patients presenting to the hospital's Psychiatric Intake Assessment Department (IAD) or Emergency Department (ED) seeking medical assistance were provided an appropriate medical screening examination within the hospital's capabilities to include ancillary services such as on call Psychiatrists, and Qualified Medical Personnel (QMPs) to determine whether or not an emergency psychiatric condition existed for 5 of 22 (Patients #1, 19, 20, 21 and 22) sampled patients. Additionally, the facility failed to ensure that psychiatric screening examinations were conducted by individuals who were determined qualified by the facility's medical staff's bylaws General Rules and Regulations.

The findings included:

1. Review of Hospital #1's medical staff bylaws rules and regulations, Section 5 revealed, "...Hospital policies regarding patient care should be followed at all times... Patients are admitted to the hospital only on the decision of a LIP [Licensed Independent Practitioner] permitted by the state...All patients presenting to the Emergency Department for care will receive a medical screening exam...the patient will be seen by either an Emergency Department physician, on-call physician, the patient's private physician, or a qualified provider (ED nurse practitioner or ED physician assistant)..."

2. Review of Hospital #1's "Provision of Care, Treatment, and Services" policy for All Behavioral Health Units, Intake assessment, Admissions Department and the Emergency Department revealed, "...To establish guidelines to describe the initial contact with the hospital by the patient...The intake is considered the first in a series of evaluations of the patient. The intake information gathered will assist in making appropriate clinical and administrative decisions...
Policy Statement...The Behavioral Health Services will operate an efficient, responsive, and coordinated intake system. The intake system will meet the emotional and informational needs of the patient...They [patients] will also be referred to an appropriate healthcare service based on: 1) the bio-psychosocial needs of the applicant [patient], and/or 2) the financial resources of the applicant...

The Behavioral Health Specialist will direct all in-coming patients...Direct to Unit...No medical clearance is needed...
Intake Department...For further Intake Assessment, Precertification, or Mobile Crisis Evaluation...
Emergency Department...Only if patient has need for medical clearance as determined by physician...

Emergency Department Referrals...Patients presenting through the Emergency Department will be triaged by the Emergency Department. If the Emergency Department physician assessed that the patient is medically stable, the Behavioral Health Specialist will interview the patient to determine if admission criteria are met for an appropriate level of care..."

3. Review of Hospital #1's "EMTALA (Emergency Treatment and Labor Act)" policy revealed, "...Any individual who presents on the property of [Name of Hospital #1] and is in need of assistance for medical conditions will be provided an appropriate medical screening examination [MSE] within the capabilities of the Emergency Department to determine whether an emergency medical condition exists...

After the medical screening, if the Emergency Department Physician determines the individual has an emergency medical condition...the individual will be provided further examination and treatment necessary to stabilize the condition..."

4. Review of Hospital #1's "Suicidal Patients and Suicide Risk Assessments)" policy for the departments of Nursing Services, Intake Department, Patients, and Medical Staff revealed, "...Purpose: To ensure each patient at risk for suicide is assessed appropriately and proper precautions are initiated...

Patients scoring at High Risk (42-58) or Severe Risk (59-68) will be reported immediately to the charge nurse and the physician. Patients with a score of 42 or above are placed on every 5 minute checks.
Any patient who verbalizes ideations involving thoughts of self-harm or suicide will be placed on Suicide Precautions and patient rounds not to exceed every 15 minutes. The level of monitoring will be based on the intensity of the suicidal thoughts and feelings..."

5. Review of Hospital #1's "The Emergency Medical Record" policy for the Emergency Department revealed, "... Emergency Department medical records shall include the following...Treatment rendered..."

6. Review of the State Health Related Board Statutes for Master's in Science (MS), Licensed Master of Social Work (LMSW) and Registered Nurses (RN) 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) to perform a MSE.

7. Medical record review revealed Patient #1 was a [AGE] year old female, homeless, unemployed, had no insurance and was self pay. The patient had diagnoses that included Schizophrenia, Bipolar, and Anxiety.

Review of the psychiatric IAD "EMTALA" log revealed Patient #1 presented via car to the psychiatric IAD on 6/13/19 at 1:33 PM with the chief complaint of "Psych", homicidal ideations and had an "Emergency Psychiatric Medical Condition." There was no documentation who determined the patient had an emergency psychiatric condition.

Review of the 6/13/19 psychiatric intake assessment conducted from 1:35 PM - 2:00 PM revealed the assessment was performed by Assessor #10, who had a Master's in Science degree (MS). There was no documentation a LIP or Psychiatrist performed an appropriate and ongoing MSE or assessment based on the patient's presenting signs and symptoms to determine if an emergency psychiatric condition existed.

Assessor #10 documented that Patient #1 had felonies and misdemeanors. The "Event(s) which led client [Patient #1] to seek treatment at this time" section revealed the patient had suicidal ideations, auditory and visual hallucinations with commands to harm others, and was responding to internal stimuli during the assessment.

Under the assessment section titled "What happened in the last 72 hours which led to the Precipitating Crisis/Chief Complaint?" Assessor #10 documented the patient had not been compliant with taking psychiatric medications in the last month. The Assessor documented the patient reported, "I just want to torture myself to death", and the patient stated, "...voices telling her to harm other people." The Assessor documented the patient's ideations were constant and increasing in frequency.

Under the patient's suicide risk assessment section the Assessor documented the risk was high with a score of 43. The risk assessment revealed the patient reported she was going to "Torture self to death...I'm tired & [and] in pain, just want to give up...I [patient] also used to hit this 'thing' in my room to kill myself...lack of support, housing problems, financial problems...severe depression per patient...very hopeless...A/V [auditory and visual] hallucinations...hearing command hallucinations...visual hallucinations...seeing black spots. responding to internal stimuli...blank stare...Impulsive, unpredictable behavior, isolation from others...Lack of coping skills 'I'm at a lost [loss] right now'...Living on the streets..."

The Assessor documented the nurse supervisor and the practitioner were notified of the high suicide risk assessment. The Assessor documented, "High Risk-Will need Inpatient tx [treatment]...Patient in need of Immediate Stabilization, medication change to ensure safety..." The "Suicide Precaution Ordered" and the "Observations" section revealed "TBD [to be determined]." There was no documentation the suicide precautions were implemented to continue proper assessment for the patient's safety. There was no documentation a qualified medical practitioner performed an assessment of the patient to determine if an emergency medical condition existed.

The Assessor documented the patient had current symptoms of "...active homicidal/violent thoughts...command hallucinations to harm others... worthlessness ...rapid mood swings...anger...agitation...poor sleep...poor appetite...impulsive behaviors...unpredictable behaviors..." The assessor documented the recommendations for acute inpatient admission related to "potential danger to self or others...Failure of less-intensive treatment...Grave disability with severe deterioration in functioning..." There was no documentation a LIP or Psychiatrist performed an assessment and provided stabilizing treatment based on the patient's presenting signs and symptoms.

Review of the 6/13/19 Crisis Assessment performed by the mobile crisis agency Licensed Master in Social Work (LMSW) employee from 8:14 PM - 8:48 PM revealed, "...Patient presented to [Name of Hospital #1]...due to S/I [suicidal ideations] and auditory hallucinations. Patient expressed suicidal thoughts...patient stated she has a desire to kill random people...mood is hostile and irritable..." The Crisis Assessment revealed, "...Patient is hostile and uncooperative. pt is not appropriate for CSU [Crisis Stabilization Unit]. Patient will be referred Involuntary to [Name of Psychiatric Hospital #3]. Patient will need to become stable on medications..."

Review of the mobile crisis Certificate of Need (CON) revealed Patient #1 was deemed an Emergency Involuntary Admission on 6/13/19 at 9:00 PM. The CON revealed, "...Patient is too high risk of danger to self and possibly others to be released into the community. Patient is not suitable for CSU or any lower level of care. Patient is involuntary, patient needs a safe and secure setting to adjust to medication and treatment. All less restrictive alternatives have been exhausted...Requires direct transportation to an admitting psychiatric facility for second certificate of need (CON) examination...OR...May be transported to an admitting psychiatric facility or [Name of a State Mental Health Department]...location for second CON examination..."
The mobile crisis assessment documented the patient was referred to Hospital #3 as an involuntary admission.

The facility sent Patient #1's medical information to Hospital #3 to review for a potential transfer from Hospital #1 to Hospital #3 as an involuntary admission.
Review of three (3) Assessment notes regarding the patient's potential transfer to Hospital #3 dated 6/14/19 revealed the following:

First note - "Called mobile crisis for telehealth 4 times...no telehealth yet." There was no time documented for this note.

Second note - "Called [name of Hospital #3]...pt [patient's] case is being reviewed. 12:48 AM."

Third note - Hospital #3's "...house Supervisor called [Hospital #1]. request lab work & [and] blood work. Need to send pt [patient] to ER [ED]." There was no time documented for this note.

Review of Hospital #1's ED Daily Log dated 6/14/19 at 8:14 AM revealed Patient #1 was taken from the hospital's psychiatric Intake Assessment department over to the ED with the chief complaint of "Psych Problem." The patient's acuity was a "Level 3-Urgent."

Review of the ED nurse's notes revealed the patient was triaged at 8:42 AM. The notes revealed, "...patient was received from another setting of care [psychiatric IAD]..."

Review of the 6/14/19 ED "Physician Documentation" notes revealed Family Nurse Practitioner (FNP) #1 documented at 8:43 AM, "...she [Patient #1] came thru intake and intake brought her to the ER [ED]..."
FNP #1 conducted an examination and at 12:06 PM documented, "...pt is medically cleared..." and transferred the patient to " [Mobile Crisis]." The patient left the ED at 12:07 PM and returned to the IAD area of the hospital. .

Record review revealed an additional Crisis Assessment was conducted by the Mobile Crisis Agency LMSW via telehealth on 6/15/19 at 5:40 AM. The LMSW documented "Crisis Plan...Take prescribed medications and go to outpt services...A safety contract was established with the patient..."

The patient was given the contact information and phone numbers to the Mobile Crisis Team, the CIT [Crisis Intervention Team] contact information for the local police department, the National Suicide Prevention Lifeline number and the Tennessee Suicide Prevention Network..."

Review of the safety contract titled "Crisis Plan" revealed there was no documentation regarding suicide.
There was no documentation the "Crisis Plan" addressed the patient's "desire to kill random people" or "voices telling her to harm other people" The patient was discharged homeless with continued psychiatric concerns involving the safety of the patient and others from the hospital. There was no documentation the patient was provided an appropriate MSE by a Qualified Medical Personnel (QMP), treatment or stabilization while in the hospital's IAD or ED.

Review of the psychiatric IAD "EMTALA" log revealed Patient #1 was a "transfer" to another facility on 6/15/19 at 6:00 AM. After almost 40 hours from the patient's arrival to Hospital #1's ED, Patient #1 was discharged homeless with a safety contract. The patient did not receive an appropriate MSE by a QMP. There was no evidence the Psychiatrists on call had been contacted in order to assess and treat Patient #1. There was no documentation the patient had been transferred for inpatient psychiatric treatment at Hospital #3.

In an interview on 6/18/19 at 4:45 PM in the conference room the Director of Intake Admissions verified on 6/15/19 at 6:00 AM Patient #1 was discharged from the hospital and not transferred to another hospital.

In an interview on 6/19/19 at 9:00 AM the Director of Intake Admissions verified all the patient's medical record had been provided.

In a telephone interview on 6/19/19 at 9:45 AM Registered Nurse (RN) #1 verified the patient came from the psychiatric Intake Assessment Department into the ED for medical clearance only to be transferred.

In a telephone interview on 6/19/19 at 10:15 AM FNP #1 verified she saw Patient #1 in the ED on 6/14/19. FNP #1 stated the patient came from the hospital's psychiatric IAD for medical clearance.
FNP #1 was asked if she made the decision that Patient #1 had an emergency psychiatric medical condition, and FNP #1 stated that she did not, and she was only providing medical clearance.
The FNP was asked who determined if a psychiatric patient had an emergency psychiatric medical condition and FNP #1 stated, "Intake Assessment makes the decision [if a patient has an emergency psychiatric medical condition]...we were just asked to medically clear her."

In an interview on 6/19/19 at 3:00 PM the Director of Intake Admissions stated the mobile crisis agency's LMSW made the determination that Patient #1 had an emergency psychiatric medical condition.
The Director of Intake Admissions was asked where the patient was for almost 2 days, from 6/13/19 at 1:33 PM - until she was discharged homeless on 6/15/19 at 6:00 AM, and the Director of Intake Admissions stated Patient #1 would have either been in IAD office, in the ED or in the IAD waiting room.
The Director of Intake Admissions stated Hospital #3 requested the second mobile crisis reassessment that was conducted on 6/15/19 at 5:40 AM via telehealth. The Director of Intake Admissions stated Hospital #3 would not accept Patient #1 because they didn't feel like Patient #1 met the criteria for inpatient admission, therefore the patient was discharged .

On 6/26/19 at 9:50 AM the surveyor re-attempted to contact Patient #1. The patient's father stated the patient was not there. The patient's father stated Patient #1 was homeless, and he had not heard from her in a week and was going to contact the police department to report her missing.

8. Medical record review revealed Patient #19 was a [AGE] year old male with a history of Schizophrenia and Depression. The patient did not have insurance.

Review of the ED "Daily Log Detail" revealed the patient (MDS) dated [DATE] at 5:52 PM via EMS (Emergency Medical Services) with the chief complaint Suicidal Ideation. The patient's acuity was a Level 3- Urgent.

Review of the ED nurse's notes revealed the patient was triaged on 5/31/19 at 5:59 PM. The notes revealed, "...Appears uncomfortable..."

Review of the ED physician notes revealed the ED physician conducted a MSE at 6:03 PM. The ED physician documented, "...presents...with anxiety, depression, over unknown circumstances, suicide ideation, but has no formulated plan, pt comes from [name of another state]. he was picked up at the police station. his girlfriend called the police. the report was that he was going to kill himself or homicidal..."

Review of the laboratory results revealed the patient's urine drug screen was positive for amphetamine and Terahydrocannabinol (THC).

Review of the ED record revealed the physician discharged the patient at 8:26 PM to mobile crisis. There was no documentation the physician performed a psychiatric assessment to determine if an emergency psychiatric condition existed, or stabilizing treatment provided to the patient. The nurse called the hospital's psychiatric IAD and the patient was sent to the hospital's psychiatric IAD.

Review of the psychiatric IAD "EMTALA" log revealed the patient (MDS) dated [DATE] at 6:45 PM with the chief complaint of "Psych." The log revealed the patient did not have an emergency psychiatric medical condition. There was no documentation who determined the patient did not have an emergency psychiatric condition.

On 5/31/19 Assessor #8, who had a Master in Science degree, performed the psychiatric assessment to determine if an emergency psychiatric condition existed and documented, "...Patient is in need of a psychiatric evaluation to determine his needs. Family (Dad) and Patient got into an argument and pt stated he began yelling, cursing & [and] hit the door because he was upset with his [father] for 'talking crap about him' Patient reported his [father] called the police..." The suicide risk assessment was documented to be medium risk at 28. There was no documentation the physician was notified of the risk assessment. There was no documentation the assessor completed the recommendations section. There was no documentation the facility provided an appropriate and ongoing MSE, performed by a Licensed Independent Practitioner or psychiatrist to determine if an emergency psychiatric condition existed.

On 5/31/19 at 10:15 PM Mobile crisis was called to conduct a crisis assessment and documented "...Client is a (21) year old...male who was transported to [Name of Hospital #1]...It was evident he is depressed...Although the depression is intense, he stated he has no desire to commit (S) [suicide] and there have been no previous attempts...is having problem due to his paranoid thoughts and the reported drug issue in his home. Client also uses drugs and he stated he is on probation for disorderly conduct...hallucinations were reported, but he us [is] unable to describe them well. Impulse control is poor and his insight and judgement skills are also weak...Client will be referred to the CSU [Crisis Stabilization Unit] for stabilization and support with mental health issues. He is willing to come and receive care and support..."
There was no documentation the facility provided an appropriate and ongoing MSE, performed by a Licensed Independent Practitioner or Psychiatrist to determine if an emergency psychiatric condition existed.

Review of the psychiatric IAD EMTALA log revealed the patient was not admitted and "Pt refused treatment" and was discharged home.

Review of the Bed Breakdown per nursing unit revealed their were beds available for Patient #19. There was no documentation why the patient was not admitted .

In an interview on 6/25/19 at 12:30 PM the Director of Intake Admissions stated Patient #19 ended up going to the crisis stabilization unit because he was "indigent", not because he refused treatment.

There was no evidence provided to this surveyor of the disposition of Patient #19.

9. Medical record review revealed Patient #20 was a [AGE] year old female with a history of Major Depressive Disorder, Substance Abuse, Back Pain and Anxiety. The patient had insurance.

Review of the ED "Daily Log Detail" revealed the patient (MDS) dated [DATE] at 11:23 AM with the chief complaint of drug abuse. The patient's acuity was a Level 3- Urgent.

Review of the ED nurse's notes revealed the patient was triaged on 4/12/19 at 11:54 AM. The notes revealed, "...Patient states: went from rehab to sober living home 5 days ago-stopped Suboxone 5 days ago...here to detox-sleepy-diarrhea-backache-fingers numb-body sore...Pain currently is 8 out of 10 on a pain scale."

Review of the ED record revealed the physician discharged the patient at 3:12 PM to Mobile Crisis. There was no documentation the physician had performed a psychiatric assessment to determine if an emergency psychiatric condition existed, or stabilization treatment provided. The nurse called the hospital's psychiatric IAD and the patient was escorted to the hospital's psychiatric IAD.

Review of the psychiatric IAD "EMTALA" log revealed the patient (MDS) dated [DATE] at 2:14 PM . The log revealed the patient had an emergency psychiatric medical condition. There was no documentation who determined the patient had an emergency medical condition.

On 4/12/19 ay 5:07 PM Assessor #1, who was an Admissions Counselor, performed the psychiatric intake assessment and documented, "...hx [history] of treatment for Major Depressive d/o [disorder] and substance abuse. Pt presented...requesting to detox off subutex..." The patient denied suicidal ideations, history of suicide attempts, homicidal ideations or psychosis. The suicide risk assessment was documented to be low risk at 9.
The assessor documented the recommendations for Outpatient/Community referral. The "pt refused" outpatient treatment. There was no documentation the a Licensed Independent Practitioner or Psychiatrist performed a psychiatric assessment to determine if an emergency medical condition existed.

In a telephone interview on 6/25/19 at 6:55 PM, Assessor #1 stated the patient "Came in for detox...didn't meet criteria for inpatient admission. She was getting restless after waiting so long. She did refuse care, refused to wait longer to get information. I gave her info for contacts...typed it up and gave it to her, but didn't include a copy for the medical record."

10. Medical record review revealed Patient #21 was a [AGE] year old female with a history of Bipolar and Depression. The patient had insurance.

Review of the ED "Daily Log Detail" revealed the patient (MDS) dated [DATE] at 4:03 PM with the chief complaint of Drug Abuse. The patient's acuity was a Level 3- Urgent.

Review of the ED nurse's notes revealed the patient was triaged on 5/28/19 at 4:43 PM. The notes revealed, "...states she was sent here by judge to go through rehab for heroin..."

Review of the laboratory results revealed the patient's urine drug screen was positive for amphetamine, barbiturate, cocaine, opiates and THC.

Review of the ED physician notes revealed the ED physician conducted a MSE at 5:17 PM. The ED physician documented, "...States she got out of rehab 4 days ago. used drugs again over the week end. Very remorseful...Medically cleared for intake/admit..."

Review of the ED record revealed the physician discharged the patient at 6:23 PM to Mobile Crisis. The nurse called the hospital's psychiatric IAD and the patient was escorted to the hospital's IAD on 5/28/19 at 6:35 PM,

Review of the psychiatric IAD "EMTALA" log revealed the patient (MDS) dated [DATE] at 6:35 PM. The log revealed the patient had an emergency psychiatric medical condition. There was no documentation who determined the patient had an emergency psychiatric condition.

On 5/28/19 at 9:30 PM Assessor #8, who had a Masters Degree in Science performed the psychiatric assessment and documented patient presented "...for opiate abuse. Patient reported she saw the judge today and he told her to get back into drug treatment...detoxing off heroin...reported she was in recovery...and left and went home and immediately relapsed..." The suicide risk assessment was documented to be low risk at 22. There was no documentation a LIP or psychiatrist performed a psychiatric assessment to determine if the patient had an emergency psychiatric condition.

The assessor documented the recommendations for "Acute Inpatient...Failure of less-intensive treatment...Less-intensive treatment not safe or feasible..." The recommendations were dated 5/28/19 and signed at 9:30 PM.

The patient also received a telehealth mobile crisis assessment on 5/28/19 at 9:40 PM documenting a voluntary readmission to Hospital #1.

There was no documentation Patient #21 was admitted to the hospital.

From 9:40 PM on 5/28/19 until 5/29/19 at 5:46 AM there was no documentation where the patient was or what treatment, if any, was being provided to the patient.

On 5/29/19 at 5:46 AM there was an addendum to the recommendations dated which stated, "Patient reported back to [Name of Hospital #1] for inpatient detox. Patient in 24 hour window. Patient continues to present for opiate abuse. Patient in need of immediate stabilization, medications and detox." This addendum was signed by Assessor #10, who had a Master's in Science degree (MS).

There was no documentation the facility provided an appropriate and ongoing MSE, performed by a Licensed Independent Practitioner, or Psychiatrist based on the patient's presenting signs and symptoms.

In an interview on 6/24/19 at 3:15 PM the Director of Intake Admissions stated Patient #21 left the hospital grounds on 5/29/19 at 12:05 AM, and returned on 5/29/19 at 4:58 PM. The Director of Intake Admissions stated the hospital practice was not to re-assess a patient if they haven't been gone for over 24 hours. The Director of Intake Admissions was unable to provide a policy for this practice.

11. Medical record review revealed Patient #22 was a [AGE] year old male with a history of Schizophrenia. The patient had insurance, but was out of covered psychiatric coverage days.

The patient presented to the hospital's psychiatric IAD on 3/27/19 at 9:10 AM with the chief complaint of "Psych." The log revealed the patient had an emergency psychiatric medical condition. There was no documentation who determined the patient had an emergency medical condition.

On 3/27/19 at 9:28 AM, Assessor #9, who was a RN, performed the psychiatric intake assessment and documented, "The voices hold me back from civilization. I hear stuff like electronic sounds...I feel majorly depressed, my doctor told me to come in. I wanted to buy a pint this morning but came here instead..." The Assessor documented the patient was homeless, very manic, extremely impulsive, delusional and responding to internal stimuli. The suicide risk assessment was documented to be low risk at 16. There was no documentation a LIP or Psychiatrists performed a psychiatric assessment to determine if an emergency psychiatric condition existed.

Review of the 3/27/19 of the mobile crisis assessment conducted via telehealth at 11:43 AM revealed, "...Pt was d/c from [Name of Hospital #1] on 2/2/19 and presented to ring their door bell today. They [Hospital #1] advised him he was out of [name of insurance] psych days...Pt was demanding at the beginning of the assessment via Telehealth...he became irate and said...'I aint talking to you. Just let me go on...I am going to jack off.' [Name of Hospital #1] stated pt was masturbating in front of staff and has done so in the past...Due to being out of [name of insurance] days, pt will be referred to [name of hospital #3]..."

There was no documentation what was the patient's disposition.

In an interview on 6/25/19 at 1:30 PM, the Director of Intake Admissions stated there was no transfer form, but the Patient #22 was transferred to Hospital #3 on 3/27/19 at 9:50 PM.

12. In an interview on 6/25/19 at 12:30 PM in an administrative office the Director of Intake Admissions stated if the patient had a medium to high suicide risk assessment the physician is notified, if the patient is going to be admitted inpatient at Hospital #1.

The Director of Intake Admissions was unable to provide evidence that the suicide risk precautions were implemented on the sampled patients with medium - high risks, while patients were in the IAD.
The Director of Intake Admissions stated the psychiatrist determines if a patient has an emergency psychiatric medical condition, and that the psychiatrist was notified via phone call and does not see the patients in the IAD.
The Director of Intake Admissions stated if a patient was indigent or had [Name of State Medicaid program] then the hospital doesn't admit them and mobile crisis was notified to assess the patient and determine where the patient should go for treatment.

The Director of Intake Admissions stated the State Medicaid insurance program contracts with the mobile crisis agency and they determine where the patient goes and if they are admitted elsewhere.


The facility failed to ensure that their own Medical Staff Bylaws and Regulations as evidenced by failing to ensure that Patient #'s 1, 19, 20, 21, & 22 received an appropriate medical screening examination by qualified medical personnel in order to determine whether or not an emergency medical existed.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, policy and procedure review, Emergency Department (ED) log detail, on-all schedules, and interview, it was determined the facility failed to ensure that further evaluation and treatment was provided as required to stabilize the medical condition, within the capabilities of the staff and facility available for 4 of 22 (Patients #1, 19, 20 and 22) sampled patients. Additionally the facility failed to provide informed refusal of the risks and benefits of the medical screening examination for 2 of 22 (Patients #13 and 22) sampled patients.

The findings included:

1. Review of Hospital #1's "EMTALA (Emergency Treatment and Labor Act)" policy revealed, "...Procedure...Any individual who presents on the property of [Delta Medical Center - Hospital #1] and is in need of assistance for medical conditions will be provided an appropriate medical screening examination [MSE] within the capabilities of the Emergency Department to determine whether an emergency medical condition exists...

After the medical screening, if the Emergency Department Physician determines the individual has an emergency medical condition...the individual will be provided further examination and treatment necessary to stabilize the condition...

Definitions...'Emergency Medical Condition' A. Medical Condition
manifesting itself by acute symptoms of sufficient severity...that the absence of immediate medical attention could be reasonably be expected to result in...
Placing the health of the patient...in serious jeopardy...Serious impairment to any bodily functions...Serious dysfunction of any bodily organ or part...

The term 'to stabilize' means, with respect to an emergency medical condition as described above, that no deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer..."

2. Review of Hospital #1's "Suicidal Patients and Suicide Risk Assessments)" policy for the departments of Nursing Services, Intake Department, Patients, and Medical Staff revealed, "...Purpose: To ensure each patient at risk for suicide is assessed appropriately and proper precautions are initiated...

Policy Statement: Suicide Risk Assessment should be completed at the time of admission for all patients admitted with a mental health diagnosis regardless of the patient location/unit...A scored Suicide Risk Assessment tool will be utilized to perform risk assessments on each patient...

Patients scoring at High Risk (42-58) or Severe Risk (59-68) will be reported immediately to the charge nurse and the physician. Patients with a score of 42 or above are placed on every 5 minute checks.
Any patient who verbalizes ideations involving thoughts of self-harm or suicide will be placed on Suicide Precautions and patient rounds not to exceed every 15 minutes. The level of monitoring will be based on the intensity of the suicidal thoughts and feelings...

The problem will be added to the treatment Plan with applicable goals and interventions...A Suicide Risk Assessment may be completed every 24 hours or as deemed appropriate...Treatment team members will develop and implement the initial treatment plan, taking into consideration the patient's suicide risk assessment, plan, and lethality...

Procedure For Suicide Precautions: At risk triggers or behaviors are evidenced by, but not limited to, the following...
Pre-occupation with sad thoughts...Verbalized feelings of hopelessness...Crying and tearfulness...Self-neglect...Poor appetite or compulsive eating/drinking...Drug or alcohol withdrawals...Sleep difficulties or abnormal sleep pattern...Pre-occupation with the disposition of possessions and arrangements of unfinished business...Sudden calm in a previously agitated person, or unexplainable lifting of mod, euphoria, or excitement...Manic behavior or extremely poor impulse control...Lack or absence of support systems in a patient's life...Verbalization of suicidal feelings, threats, or plans...Superficial self-mutilatory actions...Refusal or ambivalence about making a 'No Harm' contract...Minimal insight into existing problem...Command hallucinations...Unresolved or ongoing grief or loss...

An assigned staff member will conduct the level of monitoring ordered (every 5 minutes, 15 minutes, LOS or 1:1) and document on the Observation Record..."

Review of the "Intake Assessment" forms revealed the section titled "Suicide Risk Assessment" revealed "Notifications/Actions If Medium, High or Severe Risk" should be taken. The section revealed the Nurse Supervisor and Physician are required to be notified.

The facility policy revealed patients with High Risk (42-58) or Severe Risk (59-68) would be reported immediately to the charge nurse and the physician.

In an interview on 6/25/19 at 12:30 PM, in an administrative office, the Director of Intake Admissions (DIA) stated if the patient had a medium to high suicide risk assessment the physician is notified, if the patient is going to be admitted inpatient at Hospital #1.

Review of Hospital #1's "15 Minute Checks, 1:1 (one to one) Observation, and Care of the Suicidal Patient" policy for the Emergency Department revealed, "...Any patient who verbalizes ideations involving thoughts of self-harm or suicide, thoughts of harming others or other self-harm behaviors...will be placed on either Suicide Precautions (15 minute assessment and documentation) or 1:1 observation (staff member constantly with the patient not more than an arm's length away and documents at 15 minute intervals) depending on the intensity of the thoughts and feelings or behaviors..."

Review of Hospital #1's "Refusal Of Service" policy for the departments of Emergency Department and Behavioral Services revealed, "...AMA [Against Medical Advice]...To assure patients are made aware of the risks involved in leaving against medical advice or prior to a medical screening...

This 'Withdrawal of Request Services' form is to be utilized for patients who are refusing an examination, treatment or transfer to another facility. Patients wishing to leave Against Medical Advice will be asked to sign an AMA form. The Emergency Department or RN [Registered Nurse] may complete this form...
If the patient refuses to sign the release, it must be documented on the ED record, including the extent and nature of the examination, any treatment started and the risks of leaving prior to examination and/or treatment...The nurses would note to the patient and their family the benefits of services needed and the risks of leaving the facility...

Whenever possible the physician should be aware and have an opportunity to talk with any patient leaving AMA. In regards to refusal of medical screening, the physician should be notified that the patient is leaving whenever feasible, especially if the patient is triaged as urgent or emergent..."

3. Medical record review revealed Patient #1 presented to the psychiatric Intake Assessment Department (IAD) on 6/13/19 at 1:33 PM with a history of Schizophrenia, Bipolar and Anxiety. The medical record documented the patient was homeless.

The psychiatric IAD "EMTALA" log revealed the patient presented with the chief complaint of "Psych" and had an emergency psychiatric medical condition. There was no documentation who determined the patient had an emergency psychiatric condition.

Review of the 6/13/19 Intake Assessment conducted at 1:35 PM - 2:00 PM documented following:

The patient had suicidal ideations, auditory and visual hallucinations with commands to harm others, and was responding to internal stimuli during the assessment.

The patient was not compliant with her psychiatric medications for the last month. She reported that she was tired, in pain and wanted to torture herself to death. The patient also reported hearing voices that were telling her to randomly harm other people.

The patient had a lack of support, housing problems, financial problems, severe depression, hopelessness auditory and visual hallucinations, impulsive and unpredictable behaviors, isolation from others, lack of coping skills and was homeless and living on the streets. The patient's suicide risk assessment was high, with a score of 43. The "Suicide Precaution Ordered" and the "Observations" section of the Intake Assessment documented "TBD [to be determined]."

The Intake Assessment revealed the assessor documented the nurse supervisor and the practitioner were notified of the high suicide risk assessment. The Assessor documented the patient was in need of immediate stabilization and medication change to ensure safety. The Intake Assessment revealed the patient was a potential danger to self or others and recommended acute inpatient assessment.

Record review revealed Patient #1 (MDS) dated [DATE] at 1:33 PM and was not discharged until almost 2 days later on 6/15/19 at 6:00 AM. There was no documentation stabilization treatment was provided to Patient #1 during this time period or re-assessments performed. There was no documentation the hospital utilized its Psychiatric services to provide stabilization and treatment to Patient #1. There was no documentation a suicide precaution plan was developed and implemented to provide stabilizing treatment while the patient was in the psychiatric IAD waiting area. Patient #1 was discharged homeless with continued psychiatric concerns involving the safety of the patient and others.

In an interview on 6/25/19 at 12:30 PM, the Director of Intake Admissions was unable to provide evidence that the suicide risk precautions were implemented while patients were in the psychiatric IAD.

5. Medical record review revealed Patient #13 was a [AGE] year old male that (MDS) dated [DATE] at 2:08 PM with the chief complaint of "Back Pain."

Review of the nurses notes revealed a triage assessment was conducted at 2:30 PM and revealed, "...low back pain...Pain is currently 8 out of 10 on a pain sale..." The nurse's note revealed at 3:16 PM the patient signed an Against Medical Advice (AMA) form.

Record review revealed a physician's note dated 6/4/19 at 3:30 PM, "...Pt was seen in local office yesterday. Was given Toradol injection with no relief. Wants his hydrocodone 10 mg (milligrams) filled...has run out of pain medications, hydrocodone...The problem was sustained from a chronic condition, the patient has known disc disease...The patient symptoms are alleviated by hydrocodone, the patient symptoms are aggravated by bending, movement...ED Course: Offered patient Demerol injection. He again stated he did not want a shot, just his pain pills. When I told him we would not refill his pain medications as he just saw his PCP [primary care provider] yesterday, he became upset and left AMA. I told him he needed to see an orthopedic doctor and directed him to [Name of an orthopedic clinic] to the walk in clinic..." The physician's note revealed the patient left against medical advice at 3:37 PM.

Review of the ED "Daily Log Detail" log revealed the patient left "AMA" on 6/4/19 at 3:39 PM.

There was no documentation the patient received medical advice or of the risks of leaving. There was no AMA form in the patient's ED record. There was no documentation the hospital had utilized its medical services to provide stabilization and treatment for the patient's back pain.

6. Medical record review revealed Patient #19 presented to the psychiatric Intake Assessment Department (IAD) on 5/31/19 at 6:45 PM with a history of Depression and Schizophrenia.

The psychiatric IAD "EMTALA" log revealed the patient presented with the chief complaint of "Psych." The hospital laboratory results revealed the patient was positive for amphetamines and Tetrahydrocannabinol (THC).

Review of the 5/31/19 Intake Assessment, conducted at 6:56 PM, documented the patient had and argument with his father, began yelling, cursing and physically hit the door. The police were called and the patient was transported to the police station, with the patient reporting he was going to kill himself. The patient's suicide risk assessment was documented to be medium risk at 28. Mobile Crisis was notified.

Review of the 5/31/19 Mobile Crisis assessment, conducted at 10:15 PM revealed the patient was depressed, having paranoid thoughts, uses drugs and had poor impulse control. The assessment recommended a Crisis Stabilization Unit (CSU - a waiting area for patients to see if their symptoms stabilize - used for patients with no insurance for hospital admission).

The psychiatric IAD "EMTALA" log revealed the patient was discharged home.

There was no documentation stabilization treatment was provided to Patient #19 during this time period. There was no documentation the hospital utilized its Psychiatric services to provide stabilization and treatment to Patient #19.

In an interview on 6/25/19 at 12:30 PM, the Director of Intake Admissions stated Patient #19 ended up going to the CSU because he was "indigent" not because he refused treatment.

7. Medical record review revealed Patient #20 presented to the psychiatric Intake Assessment Department (IAD) on 4/12/19 at 2:14 PM with a history of Major Depressive Disorder, Substance Abuse, Back Pain and Anxiety. The patient had insurance.

The psychiatric IAD "EMTALA" log revealed the patient had an emergency psychiatric medical condition.

Review of the 4/12/19 Intake Assessment conducted at 5:07 PM documented the following:

The patient was taking Suboxone to treat her drug abuse, stopped taking the Suboxone 5 days previously, and was having the withdrawal symptoms of diarrhea, sleepiness, backache, finger numbness and body soreness and reported pain at a level 8 on a scale of 1-10 (with 10 being the most severe pain). The IAD recommended the patient for outpatient treatment.

In a telephone interview on 6/25/19 at 6:55 PM, Assessor #1 stated the patient came for detox, was referred to outpatient because she didn't meet criteria for inpatient admission. Assessor #1 stated she was getting "restless" after waiting so long.

There was no documentation stabilization treatment was provided to Patient #20 during this time period. There was no documentation the hospital utilized its Psychiatric services to provide stabilization and treatment to Patient #20.

8. Medical record review revealed Patient #22 presented to the psychiatric Intake Assessment Department (IAD) on 3/27/19 at 9:10 AM with a history of Schizophrenia.

The psychiatric IAD "EMTALA" log revealed the patient had an emergency psychiatric medical condition.

Review of the 3/27/19 Intake Assessment conducted at 9:28 AM documented the following:

The patient reported "...I hear stuff like electronic sounds...I feel majorly depressed...I wanted to buy a pint [of alcohol] this morning..." The Assessor documented the patient was homeless, very manic, extremely impulsive, delusional and responding to internal stimuli.

Review of the 3/27/19 of the mobile crisis assessment conducted via telehealth at 11:43 AM revealed the patient was recently discharged from an inpatient hospital admission. Presented to this hospital and was told he was out of insurance psych days. He was referred to hospital #3.

In an interview on 6/25/19 at 1:30 PM, the Director of Intake Admissions stated there was no transfer information, but the patient was transferred to Hospital #3 on 3/27/19 at 9:50 PM.

There was no documentation stabilization treatment was provided to Patient #22 during this time period. There was no documentation the hospital utilized its Psychiatric services to provide stabilization and treatment to Patient #22.
VIOLATION: DELAY IN EXAMINATION OR TREATMENT Tag No: A2408
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility polices, record review and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) were not discouraged from seeking a Medical Screening Examination (MSE) to inquire about method of payment for 1 of 1 (Patient #16) sampled patient that left without being seen (LWBS).

The findings included:

1. Review of Hospital #1's "EMTALA (Emergency Treatment and Labor Act)" policy revealed, "...All patients presenting to [Name of Hospital #1] regardless of...ability to pay...will be provided a medical screening...The screening or the further examination of patient necessary to determine emergent medical condition will not be delayed in any way to determine method of payment or insurance status...

Procedure...Any individual who presents on the property of [Name of Hospital #1] and is in need of assistance for medical conditions will be provided an appropriate medical screening examination [MSE] within the capabilities of the Emergency Department to determine whether an emergency medical condition exists..."

Review of Hospital #1's "Refusal Of Service" policy for the departments of Emergency Department and Behavioral Services revealed, "...Patient Who Leaves Without Being Seen (LWBS)...
Efforts will be mad to insure that the patient hears his/her name called or if he/she is present in the department. Each patient will be called at least two times, and documented no answer...The nurse would still complete a Refusal of Service Form, with the patient's name. date and nurse witness but note the patient left without being seen..."

2. Medical record review revealed Patient #16 was a [AGE] year old female that did not have insurance and was "Self Pay."

Review of the ED "Daily Log Detail" revealed the patient (MDS) dated [DATE] at 12:37 PM with the chief complaint of "Vomiting." The ED log revealed the patient "Eloped: LWBS" at 1:00 PM.

Review of the ED nurse's notes revealed, "Outcome: 13:00 [1:00 PM] Patient left the ED."

In an interview on 6/24/19 at 2:00 PM the Health Information Manger employee stated there was no additional information and all records for Patient #16 had been provided.

In an interview on 6/24/19 at 3:45 PM, the Emergency Department Manager verified all records for Patient #16 had been provided.

Patient #16 was contacted via telephone by the surveyor to inquire why the patient left the ED before being seen. In a telephone interview on 6/25/19 at 2:05 PM Patient #16 stated, "The person I registered with told me there would be a $50 deposit to be seen...The nurse also told me I would have to pay for the visit."
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, policy and procedure review, Emergency Medical Treatment and Labor Act (EMTALA) log review and staff interview it was determined the facility failed to ensure an appropriate transfer was provided for an individual who was transferred to another hospital by failing to ensure the receiving hospital had available space and qualified personnel, agreed to accept the transfer, send copies of medical record related to identified emergency psychiatric medical condition, and completed a written certificate of transfer for 1 of 1 sampled patient (Patient #22) transferred inappropriately.

The findings included:

1. Review of Hospital #1's EMTALA policy revealed, "...All patients presenting to [Name of Hospital #1] regardless of race, creed, ethnicity, ability to pay, disability or sexual preference will be provided a medical screening...After the medical screening, if the Emergency Department Physician determines the individual has an emergency medical condition...the individual will be provided further examination and treatment necessary to stabilize the condition...
If [Name of Hospital #1] is not able to provide the level of care the patient requires, it is the responsibility of the hospital and physician to...Provide medical care to stabilize the patient for transport so that...the individual's condition will not likely deteriorate materially as a result of the transfer...Contact a physician at the receiving health facility which has the appropriate capability of treatment and obtain acceptance of the transfer of the individual...Contact the receiving hospital to obtain acceptance...
Arrange for transport of the individual by qualified personnel and equipment...Document on the patient's record...The need for transfer, risks, and benefits of transfer...Accepting physician and facility...Responsibility during transfer...Time of contact of the facility and physician...Name of accepting physician and vital signs at time of transfer...Report was given to accepting facility...Complete and sign the following forms, which become a permanent part of the medical record...a. Patient Transfer form b. Patient's Refusal of Transfer, Examination, and/or Treatment form...Definitions...'Emergency Medical Condition...
Medical Condition manifesting itself by acute symptoms of sufficient severity...that the absence of immediate medical attention could be reasonably be expected to result in...Placing the health of the patient...in serious jeopardy...Serious impairment to any bodily functions...Serious dysfunction of any bodily organ or part...The term 'to stabilize' means, with respect to an emergency medical condition as described above, that no deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer..."

2. Medical record review revealed Patient #22 was a [AGE] year old male with a history of Schizophrenia.

Record review revealed the patient presented to the hospital's psychiatric IAD and had a previous hospitalization at Hospital #1.

Review of the psychiatric IAD EMTALA log revealed the patient (MDS) dated [DATE] at 9:10 AM with the chief complaint of "Psych." The log revealed the patient had an emergency psychiatric medical condition. There was no documentation who determined the patient had an emergency psychiatric condition.

Record review revealed Assessor #9, who was not a Licensed Independent Practitioner (LIP) or psychiatrist conducted a psychiatric intake assessment on 3/27/19 at 9:28 AM. The Assessor documented the patient presented reporting that he was hearing voices, hearing electronic sounds and was majorly depressed. The Assessor documented the patient was homeless, very manic, extremely impulsive, delusional and responding to internal stimuli. The Assessor documented the patient's suicide risk to be low risk at 16. The Assessor recommended Acute Inpatient hospitalization related to, "Acute psychiatric condition requires 24 hour skilled nursing/medical oversight" and "Less-intensive treatment not safe or feasible"

The patient was also assessed by a mobile crisis agency, because the patient did not currently have insurance days. The 3/27/19 Crisis Assessment was conducted via telehealth by a mobile crisis agency at 11:43 AM.
Review of the 3/27/19 assessment revealed the patient had recently been discharged from Hospital #1 on 2/2/19. The patient presented a second time to Hospital #1 on 3/27/19. Hospital #1 advised Patient #22 that he was out of psychiatric coverage days with his insurance. The patient was exhibiting acute symptoms/behaviors. The assessment revealed, "...Due to being out of [name of insurance] days, pt will be referred to [name of hospital #3]. Pt is too acute for crisis stabilization unit..."

There was no documentation in the medical record or on the log what the disposition of Patient #22 was or if the patient had been transferred to Hospital #3.

In an interview on 6/25/19 at 1:30 PM, the Director of Intake Admissions stated Patient #22 was transferred to Hospital #3 on 3/27/19 at 9:50 PM, and verified there was no transfer form, or the information regarding the transfer.

Review of Hospital #3's admission History and Physical for Patient #22 dated 3/28/19 revealed the patient was delusional, agitated, and "...Talks making no sense..." The patient was admitted to Hospital #3 from 3/27/19 - 4/11/19 with diagnoses that included Manic Schizoaffective Disorder and Cocaine Use Disorder.