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Based on observation, interview and record review, the hospital failed to comply with the requirement to provide necessary stabilizing treatment, to 11 of 20 sampled patients, who presented to the hospital with an emergency medical condition.

Findings:

During the entrance conference of an EMTALA survey an interview was conducted with the Assistant Administrator (AA), on 2/2/12 at 10:05 A.M. The AA stated that the hospital had a dedicated Emergency Department that treats psychiatric emergencies. The hospital's Emergency Department is called the Emergency Psychiatric Unit (EPU). The AA further explained that medical emergencies beyond their scope of services were transferred out and that the hospital had a transfer agreement with another local hospital. Initially, a one third test was performed by reviewing 20 randomly sampled EPU patient visits from the prior calendar year. 100 % of the 20 sampled patients reviewed were unscheduled outpatient appointments who received medical screening and stabilization treatment. However, during a record review of 20 sample patients, who were transferred to another local ED by activating the 911 emergency medical system, it was determined that, 11 out of the 20 sampled patients, did not receive any type of stabilization treatment in the EPU. Once the EPU physician determined the patient had an emergency medical condition requiring stabilization, the patient was transferred to a local Emergency Department after calling 911. (See Tag A-2407)

Based on observation, interview and record review, the hospital failed to make an attempt to stabilize 11 of 20 sampled patients ( 23, 24, 25, 26, 27, 28, 29, 30, 31, 35, 36) with emergency medical conditions, prior to transferring the patients to a local emergency department (ED).

Findings:

During the entrance conference of an EMTALA survey, an interview was conducted with the hospital's Assistant Administrator (AA), on 2/2/12 at 10:05 A.M. The AA stated that the hospital had a dedicated ED that treated psychiatric emergencies. The AA further stated that medical emergencies beyond the hospital's scope of services were transferred out. He stated that the hospital had a transfer agreement with another local hospital.

A tour of the hospital's Emergency Department/Emergency Psychiatric Unit (EPU), was conducted on 2/2/12 at 1:00 P.M. There was signage in the waiting room that read:

You have the right to:
- Medical Screening.
- Stabilization Treatment.
(including treatment of unborn child)
- If necessary, transfer.

There were four consultation rooms in the EPU. Each of the consult rooms had a sign with the same verbiage.

On 2/2/12 at 1:05 P.M., an interview was conducted with the physician/medical doctor (MD 1) in charge of the EPU. MD 1 stated that the EPU handled medical emergencies in two different ways. When a patient arrived with a very emergent medical condition, the EPU MD will order 9-1-1 to be called. MD 1 stated that 80% of the time the patient is taken by the ambulance to one particular hospital. Some EPU MDs will call that hospital to notify them of the probable transfer. Other EPU MDs did not call that hospital because they could not be certain where the ambulance would take the patient. If a patient arrived with a non-emergent medical condition, first-aid would be rendered and the patient would be transferred to the hospital that held the transfer agreement. The EPU MD will always call the transfer hospital emergency department MD prior to the transfer. MD 1 stated that this would be only for non life or death situations. MD 1 gave the example of a patient arriving in the EPU with altered consciousness from an overdose. MD 1 explained that the EPU would call 9-1-1 to have that patient taken to a hospital emergency department.

A review of the hospital's policy and procedure entitled, "Medical Triage" indicated that, "Emergency Psychiatric Unit (EPU) shall provide emergency psychiatric care. Patients with accompanying medical problems shall be triaged and referred for general medical care, within the range of available resources....EPU staff shall observe the following guidelines:...If an acute and life-threatening emergency arises, provide Cardio-pulmonary Resuscitation (CPR) intervention and call 9-9-1-1. The responding Paramedic Unit shall choose a facility to which they shall transport a patient."

On 2/3/12 at 11:20 A.M., the EPU Patient Log was reviewed for the calendar year of 2011. From 1/1/11 through 5/24/11, there was no record on the EPU Patient Log of the disposition of the EPU patient. Beginning on 5/25/11 through 12/31/11, there was a "referral to" column on the EPU Patient Log documenting the disposition of the EPU patient.

The following EPU patients were transferred to another hospital's ED after activating the 9-1-1 emergency call system. A review of the patient's medical records was conducted on 2/3/12 at 1: 40 P.M. There was no documentation on the patient's medical record that stabilization treatment had occurred in the EPU prior to the patient's transfer:

1. Patient 23 presented to the hospital's Emergency Psychiatric Unit (EPU) on 6/25/11, according to the Face Sheet. There was documentation in a nursing note, dated 6/25/11 and timed 11:10 P.M., that "Pt. (patient) stuporous and difficult to arouse and promptly promptly fell back asleep each time awakened. breathing slowed. Oriented to self only. Unable to provide accurate information but did report he suffers from htn (hypertension) and cardiac prob (problem). Pt. obese. Evaluated by psychiatrist and sent 911 to [name of hospital] for medical clearance for altered medical status and to R/O (rule out) OD (overdose) on unknown substance." There was no documentation in Patient 23's medical record that any treatment was rendered to him in the EPU.

2. Patient 24 presented to the hospital's EPU on 7/24/11, according to the Face Sheet. On 7/24/11 at 11:50 P.M., the EPU MD documented the following progress note in Patient 24's medical record: "Patient arrived being brought in by [police] on a 5150 (involuntary psychiatric hold)...He was extremely agitated on arrival and even before getting to EPU while in admissions department he accidentally hit his back of his head as he was combative with the [police] officer. Occiput area (back part of the head) - bleeding...Because he was very combative he was given Valium (a tranquilizer) 10 mg. (milligram) p.o. (by mouth) which pt. (patient) agreed to take. Please evaluate and tx (treat) for head injury." There was no documentation in Patient 24's medical record that any treatment was rendered to him in the EPU for his head injury.

3. Patient 25 presented to the hospital's EPU on 8/19/11, according to the Face Sheet. There was documentation in a nursing note on the EPU triage form, dated 8/19/11 and timed 4:45 P.M., that "Pt. (patient) seen and evaluated by psychiatrist. ordered to send pt. to [name of hospital] for medical clearance. Patient claimed that he took and OD (overdosed) on 15 tabs (tablets) of Seroquel (anti-psychotic) and 30 tabs of Zoloft (anti-depressant) 50 mg. few hours ago. Pt. left with paramedics on their gurney via 911 ambulance. All paper work given to ambulance crew." There was no documentation in Patient 25's medical record that any treatment was rendered to him in the EPU for his overdose.

4. Patient 26 presented to the hospital's EPU on 8/27/11, according to the Face Sheet. Upon admission to the EPU, Patient 26 reported left sided upper and lower extremity numbness with slurred speech. There was documentation in a nursing note, dated 8/27/11 and timed 9:15 P.M., that "patient seen by [psychiatrist's name] and he instructed to call 911 - Paper work given to 911 ambulance crew. Pt. (patient) left atop their gurney. Paramedic stated that they will take him to [name of hospital]. There was no documentation in Patient 26's medical record that any treatment was rendered to him in the EPU for his left sided numbness and slurred speech.

5. Patient 27 presented to the hospital's EPU on 10/2/11, according to the Face Sheet. According to the EPU Psychiatric Evaluation, Patient 27 came to the unit voluntarily complaining of auditory hallucinations. It is further documented that, during the interview by the Psychiatrist, "the patient keels over and states that he is in excessive pain. States that his chest is hurting him He rates it as an 8 out of 10. He states it radiates down his left arm. he states he is having difficulty breathing. The patient adds that he has recently had a heart operation where he had four stents placed. He states he was given numerous medications to manage it, but has not been compliant with taking the meds (medication). At this time 911 was initiated. The patient appears to be experiencing a coronary event and the patient's life appears at risk." There was no documentation in Patient 27's medical record that any treatment was rendered to him in the EPU for his chest pain.

6. Patient 28 presented to the hospital's EPU on 12/12/11, according to the Face Sheet. There was documentation in a nursing note, dated 11/22/11 and timed 11:05 P.M., "Patient presented with slurred speech, unsteady gait. Patient divulged that he had consumed approx (approximately) 10 mg (milligrams) Klonopin (anti-anxiety medication), 250 mg Seroquel (anti-psychotic), unknown amount of Ambien (sedative-hypnotic) and Zoloft (anti-depressant) between 8-9 pm..stated he was going to try to sleep." There were three other nursing note entries. One was dated 11/22/11 at 11:10 P.M., and read "911 activated by [name of psychiatrist]." and at 11:13 P.M. "Paramedics arrived and transported to ER (Emergency Room) and, lastly, at 11:17 P.M. "Pt. (patient) exited via paramedics to ER...Paramedics did not report specific hospital being transported prior to departure." There was no documentation in Patient 28's medical record that any treatment was rendered to him in the EPU for the patient's overdose.

7. Patient 29 presented to the hospital's EPU on 12/12/11, according to the Face Sheet. It was documented in the Triage Nurse Notes, dated 12/12/11 and timed 4:13 A.M., that "Patient was brought in by police and was responsive and able to walk. During triage she become unresponsive and unable to sit up. She was transferred to a gurney and can only be woken by sternal rub and can't follow commands." There was a physicians order on 12/12/11 at 4:40 P.M., that read "Call 911 to transport patient to a medical ER (Emergency Room) for eval (evaluation) of altered mental status." On 12/12/11 at 5:10 A.M. a nurse documented "pt. (patient) was sent out for medical clearance via 911 system..." There was no documentation in Patient 29's medical record that any treatment was rendered to her in the EPU for her sudden alteration in mental status.

8. Patient 30 presented to the hospital's EPU on 10/24/11 according to the Face Sheet. It was documented in a nursing note, dated 10/25/11 and timed 12:40 A.M., that "Pt. (patient) was seen and evaluated by [name of psychiatrist] when in the middle of her interview, the Pt. was having seizure episode. That lasted for approximately 60 sec. (seconds). sitting position with his head leaning on the table on top of his left arm. 911 was immediately called for medical assistance..." Another nursing note, dated 10/25/11 and timed 12:55 A.M., documented that "Paramedics came into the triage room and report was given. They brought the Pt. atop of the gurney with unlabored breathing and normal skin color and temp (temperature), awake and confused." There was no documentation in Patient 30's medical record that any treatment was rendered to him in the EPU for his seizure episode.

9. Patient 31 presented to the hospital's EPU on 12/31/11 according to the Face Sheet. It was documented in Patient 31's EPU Psychiatric Evaluation that Patient 31 was "brought to the Emergency Psychiatric Unit on a 5150 (psychiatric hold) by the [name of city] police. The patient has taken an overdose of medication...The patient has a number of medical problems and says that she took about 100 pills. She did vomit. She says that she took Restoril (sleeping pill), Seroquel (anti-psychotic), and Paxil (anti-depressant) and she has been drinking." In the Treatment Plan section of the EPU Psychiatric Evaluation it stated, "The patient has been turned over to the 911 medical responders, to be taken to a hospital emergency room." There was no documentation in Patient 31's medical record that any treatment was rendered to her in the EPU for her overdose.



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10. Patient 35 presented to the hospital's Emergency Psychiatric Unit (EPU) on 11/25/11, per the Face Sheet. According to Progress Notes dated 11/25/11 at 1:45 P.M., Patient 35 was diabetic and had a blood sugar value of 556. There was documentation in the Progress Notes by nursing dated 11/25/11 at 2:10 P.M., Patient 35 complained of "pins and needles bilat (bilaterally) feet and hands." Per the same Notes, 911 was called at 1:45 P.M. and the paramedics took Patient 35 out of facility on a gurney. There was no documentation in Patient 35's medical record to show that any treatment was rendered to him in the EPU.

11. Patient 36 presented to the hospital's Emergency Psychiatric Unit (EPU) on 10/4/11 per the Face Sheet. According to an EPU Psychiatric Evaluation dated 10/4/11, Patient 36 was recently discharged from a cardiac care unit, had a history of a cardiac stent and other cardiac problems. Patient 36 was given Zyprexa (a medication to treat psychotic disorders) 5 mg intermuscular to help manage his acute psychotic agitation and threatening behavior. Per the Evaluation, within 5 minutes of administering the injection, Patient 36 had a precipitous drop in his blood pressure, 70's over 40s, 9-1-1 was called and code blue status was activated. The paramedics initiated intravenous fluids.

Based on interview and record review, the hospital failed to ensure that a written transfer form was completed indicating the reason for the transfer and documenting that the patient was aware of the risks and benefits of the transfer, for 10 of 20 sampled patients (23, 25, 26, 27, 28, 29, 30, 31, 35, 36).

Findings:

On 2/3/12 at 11:20 A.M., the hospital's Emergency Department (ED)/Emergency Psychiatric Unit (EPU) Patient Log was reviewed for the calendar year of 2011. From 1/1/11 through 5/24/11 there was no record on the EPU Patient Log of the disposition of the EPU patient. Beginning on 5/25/11 through 12/31/11 there was a "referral to" column on the EPU Patient Log documenting the disposition of the EPU patient.

The following EPU patients were transferred to another hospital's ED after activating the 9-1-1 emergency call system. A review of the patient's medical records were conducted on 2/3/12 at 1: 40 P.M. There was no documentation on the patient's medical record that a written transfer form was completed indicating the reason for the patient's transfer and documentation that the patient was aware of the risks and benefits of the transfer. In addition, there was no documentation in the patient's medical records that the receiving ED physician had been notified.

1. Patient 23 presented to the hospital's Emergency Psychiatric Unit (EPU) on 6/25/11, according to the Face Sheet. There was documentation in a nursing note, dated 6/25/11 and timed 11:10 P.M., that "Pt. (patient) stuporous and difficult to arouse and promptly promptly fell back asleep each time awakened. breathing slowed. Oriented to self only. Unable to provide accurate information but did report he suffers from htn (hypertension) and cardiac prob (problem). Pt. obese. Evaluated by psychiatrist and sent 911 to [name of hospital] for medical clearance for altered medical status and to R/O (rule out) OD (overdose) on unknown substance." There was no evidence in Patient 23's medical record that a transfer form had been completed. There was documentation that an ED MD was notified of the impending transfer.

2. Patient 25 presented to the hospital's EPU on 8/19/11, according to the Face Sheet. There was documentation in a nursing note on the EPU triage form, dated 8/19/11 and timed 4:45 P.M., that "Pt. (patient) seen and evaluated by psychiatrist. ordered to send pt. to [name of hospital] for medical clearance. Patient claimed that he took and OD (overdosed) on 15 tabs (tablets) of Seroquel (anti-psychotic) and 30 tabs of Zoloft (anti-depressant) 50 mg. few hours ago. Pt. left with paramedics on their gurney via 911 ambulance. All paper work given to ambulance crew." There was no documentation in Patient 25's medical record that a transfer form had been completed. There was no documentation that an ED MD was notified of the impending transfer.

3. Patient 26 presented to the hospital's EPU on 8/27/11, according to the Face Sheet. Upon admission to the EPU Patient 26 reported left sided upper and lower extremity numbness with slurred speech. There was documentation in a nursing note, dated 8/27/11 and timed 9:15 P.M. that "patient seen by [psychiatrist's name] and he instructed to call 911 - Paper work given to 911 ambulance crew. Pt. (patient) left atop their gurney. Paramedic stated that they will take him to [name of hospital]. There was no documentation in Patient 26's medical record that a transfer form had been completed. There was no documentation that an ED MD was notified of the impending transfer.

4. Patient 27 presented to the hospital's EPU on 10/2/11, according to the Face Sheet. According to the EPU Psychiatric Evaluation, Patient 27 came to the unit voluntarily complaining of auditory hallucinations. It is further documented that, during the interview by the Psychiatrist, "the patient keels over and states that he is in excessive pain. States that his chest is hurting him He rates it as an 8 out of 10. He states it radiates down his left arm. he states he is having difficulty breathing. The patient adds that he has recently had a heart operation where he had four stents placed. He states he was given numerous medications to manage it, but has not been compliant with taking the meds (medication). At this time 911 was initiated. The patient appears to be experiencing a coronary event and the patient's life appears at risk. There was no documentation in Patient 27's medical record that a transfer form had been completed. There was no documentation that an ED MD was notified of the impending transfer.

5. Patient 28 presented to the hospital's EPU on 12/12/11 according to the Face Sheet. There was documentation in a nursing note, dated 11/22/11 and timed 11:05 P.M. "Patient presented with slurred speech, unsteady gait. Patient divulged that he had consumed approx (approximately) 10 mg (milligrams) Klonopin (anti-anxiety medication), 250 mg Seroquel (anti-psychotic), unknown amount of Ambien (sedative-hypnotic) and Zoloft (anti-depressant) between 8-9 pm..stated he was going to try to sleep." There were three other nursing note entries. One was dated 11/22/11 at 11:10 P.M., and read "911 activated by [name of psychiatrist] ." and at 11:13 P.M. "Paramedics arrived and transported to ER (Emergency Room) and, lastly, at 11:17 P.M. "Pt. (patient) exited via paramedics to ER...Paramedics did not report specific specific hospital being transported prior to departure." There was no documentation in Patient 28's medical record that a transfer form had been completed. There was no documentation that an ED MD was notified of the impending transfer.

6. Patient 29 presented to the hospital's EPU on 12/12/11, according to the Face Sheet. It was documented in the Triage Nurse Notes, dated 12/12/11 and timed 4:13 A.M., that "Patient was brought in by police and was responsive and able to walk. During triage she become unresponsive and unable to sit up. She was transferred to a gurney and can only be woken by sternal rub and can't follow commands." There was a physicians order on 12/12/11 at 4:40 P.M. that read "Call 911 to transport patient to a medical ER (Emergency Room) for eval (evaluation) of altered mental status." On 12/12/11 at 5:10 A.M. a nurse documented "pt. (patient) was sent out for medical clearance via 911 system..." There was no documentation in Patient 29's medical record that a transfer form had been completed. There was no documentation that an ED MD was notified of the impending transfer.

7. Patient 30 presented to the hospital's EPU on 10/24/11, according to the Face Sheet. It was documented in a nursing note, dated 10/25/11 and timed 12:40 A.M., that Pt. (patient) was seen and evaluated by [name of psychiatrist] when in the middle of her interview, the Pt. was having seizure episode. That lasted for approximately 60 sec. (seconds). sitting position with his head leaning on the table on top of his left arm. 911 was immediately called for medical assistance..." Another nursing note, dated 10/25/11 and timed 12:55 A.M., documented that "Paramedics came into the triage room and report was given. They brought the Pt. atop of the gurney with unlabored breathing and normal skin color and temp (temperature), awake and confused." There was no documentation in Patient 30's medical record that a transfer form had been completed. There was no documentation that an ED MD was notified of the impending transfer.

8. Patient 31 presented to the hospital's EPU on 12/31/11, according to the Face Sheet. It was documented in Patient 31's EPU Psychiatric Evaluation that Patient 31 was, "brought to the Emergency Psychiatric Unit on a 5150 (psychiatric hold) by the [name of city] police. The patient has taken an overdose of medication...The patient has a number of medical problems and says that she took about 100 pills. She did vomit. She says that she took Restoril (sleeping pill), Seroquel (anti-psychotic), and Paxil (anti-depressant) and she has been drinking." In the Treatment Plan section of the EPU Psychiatric Evaluation it stated "The patient has been turned over to the 911 medical responders, to be taken to a hospital emergency room." There was no documentation in Patient 31's medical record that a transfer form had been completed. There was no documentation that an ED MD was notified of the impending transfer.

9. Patient 35 presented to the hospital's Emergency Psychiatric Unit (EPU) on 11/25/11, per the Face Sheet. According to Progress Notes dated 11/25/11 at 1:45 P.M., Patient 35 was diabetic and had a blood sugar value of 556. There was documentation in the Progress Notes by nursing dated 11/25/11 at 2:10 P.M., Patient 35 complained of "pins and needles bilat (bilaterally) feet and hands." Per the same Notes, "911 was called at 1:45 P.M. and the paramedics took Patient 35 out of facility on a gurney." There was no documentation in Patient 35's medical record that a transfer form had been completed. There was no documentation that an ED MD was notified of the impending transfer.

10. Patient 36 presented to the hospital's Emergency Psychiatric Unit (EPU) on 10/4/11, per the Face Sheet. According to an EPU Psychiatric Evaluation dated 10/4/11, Patient 36 was recently discharged from a cardiac care unit, had a history of a cardiac stent and other cardiac problems. Patient 36 was given Zyprexa (a medication to treat psychotic disorders) 5 mg intramuscular to help manage his acute psychotic agitation and threatening behavior. Per the Evaluation, within 5 minutes of administering the injection, Patient 36 had a precipitous drop in his blood pressure, 70's over 40s, 911 was called and code blue status was activated. The paramedics initiated intravenous fluids but no other basic or advanced cardiac life support was required. There was no documentation in Patient 36's medical record that a transfer form was completed, nor was there documentation that an ED physician was notified of the impending transfer.

Another interview was conducted with the Assistant Administrator (AA) on 2/6/12 at 11:00 A.M. The AA stated, that if the psychiatrist determines that a patient has a 9-1-1 situation (an imminent risk to the patient) then the patient would be at risk to take the time to complete a transfer form. The AA further stated that when 9-1-1 is activated a call is not made to the receiving Emergency Department and transfer forms are not completed.