Based on interviews and record reviews, the hospital failed to comply with the requirements of §489.24 by: Failure to provide a medical screening exam for Patient 16. (Refer to A 2406.) Failure to provide stabilizing treatment for Patients 21 and 16. (Refer to A 2407.) Failure to provide an appropriate transfer when Patients 3, 6, 8 and 10 had no signed physician certifications and no signed patient consents for transferring to another hospital. (Refer to A 2409.)

Based on interview and record review, Psychiatric Emergency Services (PES) at Hospital B failed to ensure that the physician provided a medical screening examination (MSE) for one (Patient 16) of 29 sample selected patients. Hospital B accepted Patient 16 from Hospital A as a transfer for psychiatry emergency services (PES). Upon arrival to Hospital B's PES department, Patient 16 had low blood pressures, 77/44 - 89/49. Hospital B refused to accept Patient 16 and directed the ambulance to return the patient to Hospital A without a documented medical screening. The distance between Hospital A and Hospital B was 64 miles. Findings: On 6/19/17, review of Patient 16's Emergency Department (ED) records at Hospital A showed, on 4/28/17 at 1:17 p.m., the patient was in her early twenties and arrived by wheelchair. The ED physical exam showed, Patient 16 had multiple sclerosis (a progressive neuromuscular disease leading to paralysis) and bipolar disorder. The ED vital sign record, showed the blood pressure was 104/63, on 4/28/17 at 1:16 p.m., and 102/68, on 4/29/17 at 6:10 a.m. prior to Patient 16 being transferred to PES Hospital B. The ED Physician at Hospital A wrote the following note, on 4/28/17 at 3:21 p.m.: "She [Patient 16] is medically clear for placement." The psychiatric consult from ED Hospital A, dated 4/28/17 at 2:20 p.m., showed the following note written by Psychologist 1: "Mother concerned, pt. [Patient 16] is unmedicated bipolar/psychotic. Pt. homeless...and is not taking care of ADL's [activities of daily living]". The consult record also showed Psychologist 1 placed Patient 16 on a 5150. (Section of law which allows authorized persons to place a patient who is a danger to self or others in involuntary psychiatric confinement.) Psychologist 1 also wrote under assessment of risk, "Patient meets criteria for 5150; Grave Disability. While pt does not endorse si/hi [suicide ideation/homicidal ideation] she is highly delusional...Disposition: Psychiatric hospitalization ." Review of the "Call center transcript" (Hospital A), dated 4/29/17 at 3:21 a.m. showed, MD 2 of PES Hospital B, accepted Patient 16 for transfer. The ED nursing notes from Hospital A indicated report was given, on 4/29/17 at 4:07 a.m., to the registered nurse at the PES Hospital B. The ambulance record showed Patient 16 was transferred from ED Hospital A to PES Hospital B, on 4/29/17 at 6:27 a.m., and arrived at PES Hospital B at 7:30 a.m. on 4/29/17. The medic wrote Patient 16 had stable vital signs, within normal limits. During an interview and search of the electronic medical record (EHR) at PES Hospital B, on 6/19/17 at 1:15 p.m., the Chief Administrative Officer of PES Hospital B, said there was no record of Patient 16 being at PES Hospital B. The Chief Administrative Officer indicated staff made a thorough search of the EHR and found no clinical records of Patient 16's visit, and therefore no documentation of a MSE. A document initiated at PES Hospital B, entitled "Medical Turnaround", dated 4/29/17, was provided by Hospital A. The "Medical Turnaround" document showed two blood pressures for Patient 16. The untimed blood pressures were, 77/44 and 89/49 for Patient 16. The section of the "Medical Turnaround", identified the following "action plan": "Return patient to [ED Hospital A]. Pt. must be able to transfer, has no wheelchair...hypotensive." This was signed by MD 3 at PES Hospital B. During an interview, on 5/16/2017 at 11 a.m., MD 3 at PES Hospital B, said that he sent Patient 16 back to Hospital A, without treatment, because Patient 16 had a low blood pressure. The ambulance report, dated 4/29/17, showed an arrival at PES Hospital B, at 7:30 a.m. and departure, on 4/29/17 at 7:51 a.m. The ambulance medic wrote the following narrative: "When the staff at [PES Hospital B] took their own set of vital signs for the pt [Patient 16] they refused to accept her due to a low blood pressure, and the pt has to be taken back to [ED Hospital A]." Blood pressures recorded in the ambulance on the way back to ED Hospital A were 96/72 to 100/78. Recordings of the vital signs, level of consciousness and skin signs (temperature, color and turgor), were within normal limits. On 6/20/17, review of the PES Hospital B's policy and procedure entitled, the hospital "System Emergency Medical Treatment and Active Labor Act [EMTALA]" revised 12/2014, included the following definition of medical screening exam: "...is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an individual who come to a DED [dedicated emergency department] has an Emergency Medical condition or is in Labor..." In the section of the policy and procedure, entitled, "Scope of Examination" 3., was the following: "...A hospital has an obligation to see the individual once the individual presents to the DED whether by EMS [emergency ambulance] or otherwise..." The policy required the following: "A hospital psychiatric service that is a DED...is required to comply with all EMTALA obligations...medical screening examination, necessary stabilizing treatment and an appropriate transfer...Medical Screening Examinations are provided in the following off-campus departments: c. Psychiatric Emergency Services..."

Based on record reviews and staff interviews, the Psychiatric Emergency Services (PES) failed to treat the abnormal blood pressure readings on two of twenty-nine patients (Patients 16 and 21) in the survey sample. Patient 16 had low blood pressure and was sent back to transferring hospital without treatment. Patient 21 had high blood pressure and was sent to another facility without stabilization interventions prior to transfer. These failures had the potential for Patients 16 and 21's condition to deteriorate during the transfer. Findings: 1. Review of Patient 16's Emergency Department (ED) medical records, dated 4/28/17, showed Patient 16 was a young woman in her twenties, and had multiple sclerosis and bipolar disorder. The ED physician medically cleared Patient 16. Review of the psychiatric consult from ED Hospital A, dated 4/28/17 at 2:20 p.m., showed Patient 16 was placed on a 5150. (Section of law which allows authorized persons to place a patient who is a danger to self or others in involuntary psychiatric confinement.) Psychologist 1 also wrote under assessment of risk, "Patient meets criteria for 5150; Grave Disability...Disposition: Psychiatric hospitalization ." On 6/19/17, review of the ambulance record showed Patient 16 was transferred from ED Hospital A to PES Hospital B, on 4/29/17 at 6:27 a.m., and arrived at PES Hospital B at 7:30 a.m. on 4/29/17. The medic wrote Patient 16 had stable vital signs, within normal limits. During an interview and search of the electronic medical record (EHR) at PES Hospital B, on 6/19/17 at 1:15 p.m., the Chief Administrative Officer of PES Hospital B, said there were no records of Patient 16 being at PES Hospital B. Review of the document from PES Hospital B, entitled "Medical Turnaround", dated 4/29/17, was provided by Hospital A. The "Medical Turnaround" document showed two blood pressures for Patient 16. The untimed blood pressures were, 77/44 and 89/49. The section of the "Medical Turnaround", identified as the "action plan", had the following: "Return patient to [ED Hospital A]. Pt. must be able to transfer, has no wheelchair...hypotensive." There was no documentation that Patient 16 received consideration of or treatment for the low blood pressure. The "Medical Turnaround" was signed by MD 3 at PES Hospital B. During an interview, on 5/16/2017 at 11 a.m., MD 3 at PES Hospital B, said he sent Patient 16 back to Hospital A, without treatment, because Patient 16 had a low blood pressure and required medical clearance. On 6/20/17, further review of the ambulance report, dated 4/29/17, showed an arrival at PES Hospital B, at 7:30 a.m. and departure, on 4/29/17 at 7:51 a.m. The ambulance medic wrote the following narrative: "When the staff at [PES Hospital B] took their own set of vital signs for the pt [Patient 16] they refused to accept her due to a low blood pressure, and the pt has to be taken back to [ED Hospital A]." On 6/20/17, review of the PES Hospital B's policy and procedure entitled, the hospital "System Emergency Medical Treatment and Active Labor Act [EMTALA]" revised 12/2014, in the section entitled, "Stabilization and Transfers," showed the following: "...If the patient has an EMC [emergency medical condition], the patient is to be treated in the DED [dedicated emergency department] until the condition is stabilized or the patient can be appropriately transferred. 2. Review of Patient 21's medical records showed an ambulance report dated 6/10/2017. The ambulance report indicated that the hospital's PES refused to take Patient 21 because the blood pressure was 190/110 and required a medical clearance. The Intake Evaluation at the PES indicated that Patient 21 was on 5150 hold after he became agitated at the board and care facility and threw a rock at one worker. The patient was not compliant with taking antihypertensive medication. The Intake Evaluation did not show any documentation that PES did any intervention to take Patient 21's blood pressure down either by behavioral or pharmacological intervention. The PES sent Patient 21 to a medical emergency room . Staff interviews were conducted on 6/19/2017 from 1:20 p.m. to 4 p.m., At 1:20 p.m., the Director of Risk Management said, PES takes referral from other facilities because PES is a 5150 facility. While at PES and there are medical concerns identified, the patient will be transferred to a medical facility. The Manager of PES said, that patients are triaged in the lobby. If there would be a need to transfer for a medical reason other than psychiatry, the medical stability will be determined by the psychiatrist. At 4 p.m., the Director of Risk Management said, the psychiatrist had to examine the patient first before the transfer to another medical facility. Review of the Intake Evaluation showed a 30-minute clinician time by the psychiatrist that documented the following: history of present illness, appearance and behavior to be uncooperative, a blunt affect and an assessment of mood disorder. There was no documentation of the thought process, perception, cognition, insight, gross neurological examination or known medical problems. There was no documentation of any repeat blood pressure reading.

Based on interview and record review the facility failed to provide appropriate transfers, from the emergency department (ED) to other hospitals for four (3, 6, 8 and 10) of twenty-nine patients: there were no signed physician certifications verifying discussion with the patients about the risks and benefits of transferring. There were no signed patient consents verifying the patients accepted the transfers and were informed of the risks and benefits of transferring. These failures had the potential that the patients were transferred without evidence of the need for the transfers and without the full knowledge and acceptance by the patients. Findings: 1. On 6/20/17, review of the ED record showed that Patient 8 was a young woman who was 17 weeks pregnant and experiencing vaginal bleeding, and brought into the hospital by ambulance on 6/6/17. Patient 8 was seen by ED Physician A who wrote a note, at 11:12 a.m. on 6/6/17, "...sac [amniotic fluid water bag] noted protruding from the open cervix." The Obstetric's (OB) Physician B wrote a note at 1:47 p.m., Patient 8 had cervical insufficiency (pre-term dilation of the cervix) and Physician B discussed a transfer to a neighboring facility for a cerclage (stitching of the cervix to prevent pre-mature delivery). The physician at the neighboring hospital "...accepted the patient to the ER [emergency room ]". There was no documentation that either Physician A or B explained to Patient 8, the risks and benefits of transferring to another hospital. There was no signed consent by Patient 8 accepting the transfer. At 3:12 p.m., a registered nurse wrote a transfer note: "Plan of care discussed with patient who verbalized understanding...Patient transferred to [other hospital] ER by Medics." On 6/20/17 at 3:40 p.m., during an interview, ED Physician A said the patient was transferred because OB Physician B did not feel comfortable to perform the cerclage. ED Physician A said he discussed this with Patient 8 but didn't know about signing a physician certification and nursing staff probably knew about that. At 4 p.m., Registered Nurse (RN) 1 said the nurses were responsible for initiating the transfer form and physician certification. RN 1 said the form doesn't always get initiated especially during evenings and nights. RN 1 also said if the form wasn't in the record then it wasn't initiated because the ED had a good system of sending the original of the transfer form with the patient's chart to the medical record department. 2. Review of the ED record showed Patient 10 was eight months old when she was brought to the ED by the child's mother on 3/19/17. The triage record, 3/19/17 at 6:29 p.m., showed Patient 10 fell from a bed, two and a half feet high, and was crying when the left hip was touched. An x-ray report showed a left femur (upper leg) fracture. ED Physician C wrote a note, dated 3/19/17 at 6:36 p.m., to transfer Patient 10 to a neighboring children's hospital for "further evaluation." At 7:09 p.m., Staff Person D (no title documented) wrote: "Other note: Pt going to-------[children's hospital] accepted by-------[physician] pt is going straight to ed..." At 8:39 p.m. a nursing note showed the following: "Transfer - Plan of care discussed with mother who verbalized understanding. Report given to receiving facility...A copy of the clinical chart and written transport report...sent to receiving facility with mother..." There were no signed physician certification and no signed consent for transfer. On 6/20/17 at 3 p.m., during an interview and concurrent clinical record reviews of Patient 8 and Patient 10, Director of Risk Management 2 said the medical record department did a thorough check of the records and there were no transfer forms. On 6/20/17, review of the policy and procedure entitled, "Patient Transfers for Evaluation, Diagnostic Testing or Treatment," dated 11/2014, had the following directions: "...Before a patient transfer to another facility can be initiated, the following must be in place:..Physician documentation that the patient is stable for transfer and that the patient has been advised of risks, benefits, and alternatives to transfer as appropriate (Transfer Agreement)...Nursing documentation that the patient has been accepted at the receiving facility...The original of the__________[hospital name] Transfer Checklist and copies of pertinent medical records will accompany the patient during transportation and evaluation, testing or treatment..." Review of the attachments to the above policy and procedure included a "Transfer Agreement" form entitled, "Interfacility Transfer Form Physician Certification", and "_____[hospital name] Patient Transfer Checklist". The "Interfacility Transfer Form Physician Certification" had a preprinted "Physician Certification Statement" that the risks, benefits of the transfer were explained to the patient. There were spaces for the date, time and physician name and signature. The transfer form also had a preprinted "Patient Consent for Transfer" statement acknowledging understanding of the risks and benefits and accepting of the transfer. There were spaces for the date, time and patient and witness's signature. 3. On 6/20/17, review of the ED intake information, dated 1/17/17, showed that Patient 3 was in his forties and had a chief complaint of "pancreatitis" (inflammation of the pancreas). The history and physical, dated 1/17/17 at 3:33 p.m., by the ED physician showed Patient 3 was had a history of alcohol related pancreatitis. The exam showed the abdomen was tender and had 10/10 sharp abdominal pain. On 1/18/17 at 12:37 a.m., a nurses note showed that Patient 3 was transferred to another hospital in the medical center's hospital system. There was no documentation that the physician discussed the risks and benefits of transferring with Patient 3. There was no signed consent by Patient 3 accepting the transfer. 4. On 6/20/17 review of the ED records, dated 4/8/17 at 10:03 p.m., showed Patient 6 was in his fifties, was awake, alert and cooperative when brought to the ED by ambulance, with sharp abdominal pain. The patient's preferred language was English. The ED physician wrote a note, dated 4/9/17 at 01:35 a.m., to transfer Patient 6 to another acute hospital for further treatment of a dissecting abdominal aorta. (An aortic dissection is a life threatening condition in which the inner layer of the aorta, the large blood vessel from the heart, separates from the middle layer of the aorta and blood rapidly collects between the layers and cannot circulate to the body.) Nurses notes showed Patient 6 received stabilizing treatments: intravenous fluid and medications, blood ready for transfusion, and pain medication. Patient 6 was transferred to another hospital, by ambulance accompanied by a nurse, on 4/9/17 at 3:07 a.m..The disposition status was "critical." There was no documentation in Patient 16's medical record that the physician discussed the risks and benefits of the transfer and the patient gave consent.