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Based on record reviews and interviews, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by the hospital failing to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. This deficient practice was evidenced by:

1. failure to ensure a medical screening exam was performed on 1 (Patient #20) out of 20 patients (Patients #1-#20) reviewed with an emergency medical/psychiatric condition (see findings in A-2406).

2. the transferring hospital's failure to send to the receiving facility all medical records for Patient #20 (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual's emergency medical condition, observations of signs or symptoms and preliminary diagnosis (see findings in A-2409).

Based on record review and interview, the psychiatric hospital failed to ensure all patients who presented with an emergency Medical/Psychiatric condition received an appropriate medical screening exam. The deficient practice is evidenced by failure to ensure a medical screening exam was performed on 1(Patient #20) out of 20 patients (Patients #1-#20) reviewed with an emergency medical/psychiatric condition. Findings:

Review of the hospital's policy titled "301 Admissions & Exclusionary Criteria" revised 08/2023, revealed in part: Policy - It is the policy of the Hospital to assess, admit, or refer patients on a twenty-four (24) hour per day, seven (7) days per week ... Hospital admits patients 21 (twenty-one) years of age or older.

Procedure - Referrals for Admission: 2.) All admissions to the facility are screened by the Admissions Department and Director of Nursing for clinical appropriateness. The on-call physician / practitioner is contacted by the admissions personnel or RN Charge Nurse, depending on the time of the referral, for admission approval and admit orders.

Review of Patient #20's medical record failed to reveal the provider evaluated, assessed or treated Patient #20's psychiatric condition prior to transferring the patient back to Hospital A.

In an interview on 07/15/2024 at 1:39 p.m. S2DON verified the hospital had 14 patients on 06/07/2024. He stated that did not include Patient #20. He verified the hospital had available beds for Patient #20. S2DON stated Patient #20 should have been wheeled on the stretcher to the seclusion room with enough staff to secure Patient #20 in restraints to get Patient #20 off the EMS stretcher. S2DON verified Patient #20 would have been safer here than being transferred back to the emergency department. After reviewing the admission criteria policy, S2DON verified that Patient #20 did meet admission criteria and did not meet any exclusionary criteria.

Based on record review and interviews, the hospital failed to provide documented evidence to indicate an appropriate transfer was provided for 1 (#20) of 17 patients discharge records reviewed out of a total sample of 20. This deficient practice was evidenced by the transferring hospital's failure to send to the receiving facility all medical records for Patient #20 (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual's emergency medical condition, observations of signs or symptoms and preliminary diagnosis.
Findings:

Review of the hospital's policy 315 titled, "Patient Transfers" revealed in part:
Policy - Patient transfers should allow for a minimum disruption in care and provide for continuity of care and treatment.
Procedure
1. The physician contacts the receiving facility and obtains acceptance for admission. 2. The nurse obtains the physician's order with clarification of specific data required to accompany the patient. 6. Notify the receiving facility of time transportation is expected to arrive with the patient. 7. Complete the Patient Transfer Form, which includes an overall assessment of the patient's condition prior to transfer, a listing of medications and treatments to be continued at the receiving facility and a listing of the patients belongings. Copy all appropriate record evaluations, assessments, and documentation for continuum of care and secure in a sealed envelope to be given to the receiving facility.

Review of Patient #20's Medical Record revealed in part:
PEC (physician emergency certificate) dated 06/07/2024 at 1:25 a.m. Dangerous to self, gravely disabled, unable and unwilling to seek voluntary admission.
CEC (coroner emergency certificate) dated 06/07/2024 at 12:25 p.m. Suicidal, Dangerous to self, gravely disabled, unwilling to seek voluntary admission.

Admit Orders dated 06/07/2024 at 12:00 p.m. Legal status PEC/CEC. Admission Diagnosis: blank VORB (verbal order read back) practitioner line was blank, date of order and time were blank, the nurse signature line was blank, and the licensed practitioner's signature line was blank with no date or time.

Discharge Orders are blank except for the patient's label.

Multidisciplinary Notes 06/07/2024 at 12:15 p.m. by S3RN: Patient #20 arrived via ambulance upon entering the building EMT (emergency medical technician) notified S3RN and mental health technician that the Patient #20 was very aggressive and combative. Patient had recently head butted the EMT in transport. S3RN called all staff for help due to the patient being in 4 point restraints and still launching his upper body off the stretcher. After attempting to calm the patient down, S1Physician was notified of patient arrival and current situation. Order was given at this time. Haldol 15 mg (milligrams) IM (intramuscular), Ativan 4 mg IM, and Benadryl 50 mg IM. Patient #20 remained on stretcher in 4 point restraint due to patient being extremely combative with EMT and staff. IM injection was given at 12:25 p.m. by nurse. We again attempted to calm patient down and waited on injection to take effect approximately 40 minutes (injection was ineffective). EMT's could not release patient out restraints due to patient trying to flip stretcher. S1Physician notified of and updated on situation as well as S2DON. S1Physician gave orders to transfer Patient #20 to hospital A. Hospital A accepted patient and report was given to RN in ER. Patient #20 remained on stretcher with EMT's and staff at stretcher side while we await on the arrival of another unit to transport due to extreme combative behavior. Patient left via ambulance at 2:15 p.m. in stable condition.

Review of nursing note dated 06/07/2024 by S2DON. S2DON received a call regarding a combative Patient #20 who was transferred to their hospital from hospital A. The EMT staff were not able to release Patient #20 from their stretcher due to his combative behavior. S1Physician ordered an injection that was ineffective as evidenced by the EMT's inability to release the patient from their stretcher and relinquish care to our hospital. Order received to return to hospital A to stabilize to a point of being able to have Patient #20 released from the ambulance's stretcher taking into consideration recent overdose. Transferred to hospital A remaining combative per advanced cardiac life support unit in stable condition.

Interview on 07/16/2024 at 11:33 a.m., S2DON stated Patient #20 was brought to this hospital via ambulance. He stated Patient #20 was transferred from hospital A to this hospital. He stated Patient #20 head-butted the female EMT and busted her lip. He stated Patient #20 was in soft restraints and stretcher belts in place. S2DON stated Patient #20 was not released from the soft restraints or taken off the stretcher at this hospital. He stated S1Physician was notified by phone of this incident. He stated S1Physcian ordered an as needed medication to be given to Patient #20 for aggression. He stated the as needed medication was given to Patient #20 by one of their nurses. S2DON said the medication was not effective. He stated S3RN called hospital A and spoke with a nurse in their emergency room. He stated the EMT's also spoke to the ER physician at hospital A. He stated Patient #20 was admitted here, given the medication, and then transferred to hospital A. He stated Patient #20 was brought here by a basic ambulance and because of the medication administered, Patient #20 had to be transported in an advanced trained EMT team to hospital A.

Interview on 07/16/2024 at 1:30 p.m., S3RN stated the EMT asked her if she had more staff to help with Patient #20 because he was very combative and had already head-butted the EMT and split her lip. She stated the EMT staff brought Patient #20 into the hospital via stretcher. She stated Patient #20 was very combative, trying to flip the stretcher and would try and bite when they would try and hold the gurney stable. She stated then Patient #20 would act calm. She stated EMT told her that they would not release Patient #20 from the stretcher because of him being so combative. S3RN stated that Patient #20 continued to be combative so she notified S1Physician and requested medication orders for the patient's psychosis and violence. S1Physician gave telephone orders for Haldol, Ativan and Benadryl IM. She stated she waited over thirty minutes the patient continued to be combative with cursing and verbal threats. S3RN stated the patient seemed to become more agitated so she called S1Physician and S2DON to update them on Patient #20 continued agitation and combative behavior. She continued to state that S1Physician gave her telephone orders to transfer the patient back to hospital A's emergency room. S3RN stated she called report to a nurse and the EMT transferred the patient into another ambulance and took him away. S3RN stated she did not complete a Resident Transfer Form to send to the receiving facility and did not complete the telephone discharge orders given by S1Physician.

Interview on 07/17/2024 at 1:30 p.m., following review of Patient #20's medical record, S2DON acknowledged the patient was transferred without discharge orders and without the required Resident Discharge Form which details: the patient demographics; name of receiving facility with date and time notified; diagnoses; vital signs; allergies; and medications.