1. Based on review of Capital Regional Medical Center's written self-report of an Emergency Medical Treatment and Active Labor Act (EMTALA) violation, interviews with the hospital Risk Manager (RM), Emergency Department (ED) Director, and other ED staff members, and review of the hospital EMTALA policies, the hospital failed to provide a Medical Screening Exam (MSE) for 1 of 21 patients in the sample (#21). Refer to finding in Tag A-2406. B. Based on review of Capital Regional Medical Center's written self-report of Emergency Medical Treatment and Active Labor Act (EMTALA) violation, interviews with the hospital Risk Manager (RM), Emergency Department (ED) Director, and other ED staff members, and review of the hospital EMTALA policies, the hospital failed to provide Stabilizing Treatment for 1 of 21 patients in the sample (#21). Refer to findings in Tag A-2407. C. Based on review of Capital Regional Medical Center's written self-report of Emergency Medical Treatment and Active Labor Act (EMTALA) violation, interviews with the hospital Risk Manager (RM), Emergency Department (ED) Director, and other ED staff members, and review of the hospital EMTALA policies, the hospital failed to provide an appropriate transfer of a patient with a reported unstable emergency medical condition for 1 of 21 sampled patients (#21). Refer to findings in Tag A-2409.

Based on reviews of Capitol Regional medical Center ' s written self-pf EMTALA violation, policies and procedures and the ED control log the facility failed to maintain a medical record or other related records for 1 (#21) of 21 sampled patients. The Findings: The facility submitted to the state survey agency the following potential violation self-report of an Emergency Medical Treatment and Active Labor Act (EMTALA) on 3/18/2015: "On 03/05/2015, at approximately 10:52 a.m., the patient (patient #21) entered the Walk-In entrance of our hospital which provides access to both the Emergency Department (ED) and other areas of the hospital. The policy titled " EMTALA Definitions and General Requirements " Reference Number LL.EM.001, Effective March 2, 2013 was reviewed. The policy specified in part, " When the Individual Leaves Before the EMTALA obligations is Met ...a. Purpose of the Sign-In sheet- For those individual who present to the DED who are not immediately placed in a bed, the Sign-In Sheet must be completed. The Sign-In Sheet is used to document the date and time of request for medical screening, pre-registration information ...d. The Sign-In Sheet is to be placed in the permanent medical record or scanned or stored in the electronic Horizon Patient Folder or notebook ...Logistics ...b. Open a medical record. " Record reviews of 20 sampled ED patients were selected from the ED control log. No medical record existed for sample patient #21 when he (MDS) dated [DATE]. The facility failed to ensure that their Policy and Procedure was followed as evidenced by failing to ensure that a medical record or other related records were maintained for Patient #21 on 3/5/2015.

Based on review of Capital Regional Medical Center's written self-report letter of an Emergency Medical Treatment and Active Labor Act (EMTALA) violation, interviews with the hospital Risk Manager (RM), review of the central log, and review of the hospital EMTALA policies, the hospital failed to ensure that each individual seeking care from the emergency department was added to the central log for 1 of 21 sampled patients, #21. The findings: The facility submitted to the state survey agency the following potential violation self-report of an Emergency Medical Treatment and Active Labor Act (EMTALA) on 3/18/2015: "On 03/05/2015, at approximately 10:52 a.m., the patient (patient #21) entered the Walk-In entrance of our hospital which provides access to both the Emergency Department (ED) and other areas of the hospital. The patient proceeded to the patient and Visitor Waiting Area to the left of the entry door and then walked toward our Security Officer, who was sitting at the back area of the reception desk. The Security Officer is an off-duty Deputy with the County Sheriffs Office and employed by the contracted Security service to provide security at Capital Regional Medical Center. The reception desk is U-shaped with a Receptionist sitting in the center section. The Receptionist assists those coming through the entrance that may need assistance in initiating the ED (Emergency Department) process or directions to other areas of the facility. The Security Officer was sitting on the back left side of the U-shaped desk where there is a lower desk section for use by visitors or patients in wheelchairs. When the patient went to speak with the Security Officer the patient sat in a chair across from the Security Officer. The patient and Security Officer carried on a conversation for approximately 25 minutes. The Receptionist, when we interviewed her, said she did not see the patient enter the building but later saw him sitting in the chair talking with the Security Officer. She heard the patient say he was in fear for his life and the security guard explained the Baker Act to the patient. In addition, the Receptionist said she heard the patient state that he wanted to leave but she heard the Security Officer say he had to stay at the desk. Security video footage shows that a County Sheriffs Office Deputy entered the ED at 11:25 a.m., and the Security Officer, the patient, and the Deputy walked toward the entrance of the ED. They had a conversation by the entrance to the ED and at approximately 11:33 a.m., the patient exited the ED with the Deputy and the Security Officer. Approximately 30 minutes after the patient left, the Security Officer approached the Charge Nurse and explained that the patient walked up to him at the reception desk, stated that he needed help, someone was trying to kill him and he heard voices in his head. Because of this, the officer called a Sheriff cruiser to come get the patient and take him to a Baker Act Receiving facility." The 'Baker Act' is a Florida Statute designed to protect the rights of persons with mental illnesses, and allows the judicial system, law enforcement, and under certain circumstances, certain medical professionals to have a person involuntarily taken to a psychiatric receiving facility for evaluation and treatment of a suspected psychiatric condition. The central log was requested and reviewed. Patient #21 was not recorded on the central log at any time on 3/5/15. No record existed for sample patient #21. A visit was made to the receiving facility (a psychiatric facility) for sample patient #21 on 3/26/15 at approximately 9:00 am. The receiving facility was able to confirm that patient #21 was admitted under the provisions of the Florida Baker Act on 3/5/15, by law enforcement, and identified the psychiatric diagnosis of the patient. The facility EMTALA - Florida Central Log Policy, dated 03/2015, was reviewed. The policy stated, "The hospital will maintain a Central Log containing information on each individual who comes on the hospital campus requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged ." Under the Procedure section the document states, "The Central Log, including all additional logs incorporated into the Central Log by reference, shall be maintained in the same manner and with the same central core of information. The logs must contain at a minimum, the name of the individual and whether the individual: refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged , or expired." "A log entry for all individuals who have come to the hospital seeking medical attention or who appeared to need medical attention must be made by the appropriate individual." At approximately 10:30 am on 3/25/15, and interview was conducted with the facility Risk Manager (RM). The RM confirmed the contents of the written self-report of emergency access violation, including the statements made from the receptionist, and from the security officer on duty at the time. The RM also stated that the security guards are provided by a contracted Security Agency, and the security guards are expected to follow all facility policies. Security has been retrained in hospital EMTALA policies. The RM confirmed that patient #21 was never added to the central log.

Based on review of Capital Regional Medical Center's written self-report of an Emergency Medical Treatment and Active Labor Act (EMTALA) violation, interviews with the hospital Risk Manager (RM), Emergency Department (ED) Director, and other ED staff members, and review of the hospital EMTALA policies, the hospital failed to provide a Medical Screening Exam (MSE) for 1 of 21 patients in the sample (#21). The findings are: The facility submitted to the state survey agency the following potential violation self-report of an Emergency Medical Treatment and Active Labor Act (EMTALA) on 3/18/2015: "On 03/05/2015, at approximately 10:52 a.m., the patient (patient #21) entered the Walk-In entrance of our hospital which provides access to both the Emergency Department (ED) and other areas of the hospital. The patient proceeded to the patient and Visitor Waiting Area to the left of the entry door and then walked toward our Security Officer, who was sitting at the back area of the reception desk. The Security Officer is an off-duty Deputy with the County Sheriffs Office and employed by Yale Security to provide security at Capital Regional Medical Center. The reception desk is U-shaped with a Receptionist sitting in the center section. The Receptionist assists those coming through the entrance that may need assistance in initiating the ED (Emergency Department) process or directions to other areas of the facility. The Security Officer was sitting on the back left side of the U-shaped desk where there is a lower desk section for use by visitors or patients in wheelchairs. When the patient went to speak with the Security Officer the patient sat in a chair across from the Security Officer. The patient and Security Officer carried on a conversation for approximately 25 minutes. The Receptionist, when we interviewed her, said she did not see the patient enter the building but later saw him sitting in the chair talking with the Security Officer. She heard the patient say he was in fear for his life and the security guard explained the Baker Act to the patient. In addition, the Receptionist said she heard the patient state that he wanted to leave but she heard the Security Officer say he had to stay at the desk. Security video footage shows that a County Sheriffs Office Deputy entered the ED at 11:25 a.m., and the Security Officer, the patient, and the Deputy walked toward the entrance of the ED. They had a conversation by the entrance to the ED and at approximately 11:33 a.m., the patient exited the ED with the Deputy and the Security Officer. Approximately 30 minutes after the patient left, the Security Officer approached the Charge Nurse and explained that the patient walked up to him at the reception desk, stated that he needed help, someone was trying to kill him and he heard voices in his head. Because of this, the officer called a Sheriff cruiser to come get the patient and take him to a Baker Act Receiving facility." The 'Baker Act' is a Florida Statute designed to protect the rights of persons with mental illnesses, and allows the judicial system, law enforcement, and under certain circumstances, certain medical professionals to have a person involuntarily taken to a psychiatric receiving facility for evaluation and treatment of a suspected psychiatric condition. The facility EMTALA - Florida Medical Screening Examination and Stabilization Policy, effective 3/1/13 was reviewed. The policy states: "an EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and: the individual or representative acting on the individual's behalf requests an examination or treatment for a medical condition, or a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition. The policy continues to state, and provide an example as follows: "the individual arrives on hospital property either in the DED or property other than the DED, and no request is made for evaluation or treatment, but the appearance or behavior of the individual would cause a prudent layperson observer to believe that the individual needed such examination or treatment." On 3/26/15 at approximately 3:25 pm, an interview was conducted with the ED Receptionist. The receptionist stated that on 3/5/15 she was on shift at the reception desk. She heard a man state that somebody was after him and he was in fear for his life (to the security guard). She stated it was pretty busy that day, and she was probably 20 feet away from them. She did not hear what the officer said to him. The officer did not address her at all about the incident. On 3/26/15 at approximately 3:50pm, an interview with was conducted with the ED Charge Nurse on duty on the day shift on 3/5/15. The charge nurse stated the security officer was at the nursing desk, and informed him that he had "taken care of one patient for him". The charge nurse stated the security officer explained what he had done. The charge nurse stated he sent an email to the ED Director about it, and also did an occurrence report which went to the risk manager the next day. He then stated he discussed it with ED Director. He also stated that the ED does "morning huddles" to talk about previous days events, and to put out new information to staff. Security is not involved in those huddles. The huddles were used to review EMTALA requirements with clinical staff after the event. A handout has been given out to all employees with EMTALA updates. We also have Annual EMTALA training. On 3/27/15 at approximately 12:15am, a telephone interview was conducted with the security officer on duty in the ED on the date of the incident. The officer confirmed that he was on duty that day at his part time security job with the hospital, and that he was a full time county deputy sheriff. The officer stated he was seated when a man entered the reception area. The man sat in a chair for a while, and then got up, and down a couple of times. He stated the man eventually asked him if he could help him. The officer stated he asked the man if he needed to see a doctor, and the man replied "No", he needed his help because people were trying to kill him. The officer further stated the man made comments about the "people" that were in his head and trying to kill him. The officer states he noticed what looked like healed cuts on the man's wrists. When he asked about the cuts, the man replied that he had to cut himself sometimes so the people would go away. The officer stated he called the county sheriff's office dispatch, and asked for a car to be sent to the hospital. The car arrived with 2 other officers. One officer came into the reception area, and after discussing the situation with the officer and the man, it was decided the man was a harm to himself, and he was taken to a local Baker Act receiving facility, under the Florida Baker Act law. The officer stated that he was given a pamphlet about EMTALA upon hire, approximately 2 months ago. He states he honestly just glanced at the pamphlet, not really reading it. He stated that when he saw the man exhibit what he thought was clear suicidal and paranoid behavior, he just did what he would normally do in his role as a county deputy sheriff, and he had the man taken by law enforcement for transport to a psychiatric receiving facility. He only later, after the man was escorted from the building by other officers, informed the charge nurse. That was when he was informed that he had made a mistake, and should not have done that. The officer states he has now been trained, and fully understands the requirements for the hospital when anyone comes to the hospital property, and asks for treatment, or is observed to possibly need treatment. A further review of the hospital written policy reveals a "bold font" paragraph, with the title "Baker Act Patients, which is underlined. The paragraph states: With respect to the provision of emergency services and care to patients who are being involuntarily examined under Chapter 393, Florida Statutes (the "Baker Act"), facility shall adhere to the requirements of Chapter 394, Florida Statutes, regarding patient rights and involuntary examination procedures, regardless of whether facility is designated as a receiving facility under the Baker Act. Facility shall adhere to, and maintain in the Emergency Department, copies of the provisions of the Baker Act which govern Baker Act patient rights and the involuntary examination process. To the extent that the Baker Act conflicts with EMTALA, facility shall comply with EMTALA. At approximately 10:30 am on 3/25/15, and interview was conducted with the facility Risk Manager (RM). The RM confirmed the contents of the written self-report of emergency access violation, including the statements made from the receptionist, and from the security officer on duty at the time. The RM also stated that the security guards are provided by a contracted Security Agency, and the security guards are expected to follow all facility policies. On 3/26/15 at approximately 4:00 pm an interview was conducted with the ED Director. The ED Director stated that during orientation to the facility, all staff, including contracted security guards are provided an EMTALA pamphlet. The pamphlet provides the basic guidelines for compliance with EMTALA requirements, emphasizing the medical screening examination. Since the incident occurred on 3/5/15, 100% of security officers have been re-trained on EMTALA, and a copy of the EMTALA pamphlet has been placed in a required daily reading book for security officers working in the ED. (The ED Director provided a list of all security employees with signatures attesting to receiving the EMTALA training). The other ED staff, have been required to read the EMTALA pamphlet again, and retake the Electronic EMTALA training prior to 3/30/15. The ED Director was able to account for the completion of the training requirement through an electronic report. While not all ED staff have completed the training, those who have not, have not been back to work since the incident occurred, due to leave of absence, vacation, sick leave, or as needed work status. On 3/27/15 at approximately 10:30 a.m., and interview was conducted with ED registered nurse "A". Nurse "A" was able to verbalize appropriate knowledge of EMTALA requirements, and stated she receives annual training on EMTALA, and also had EMTALA training as recently as one week ago. On 3/27/15 at approximately 10:40 am, an interview was conducted with ED registered nurse "B". Nurse "B" was able to verbalize EMTALA requirements, stated EMTALA training is required annually, and had EMTALA training last week. On 3/27/15 at approximately 10:37 am, and interview was conducted with ED registered nurse "C". Nurse "C" was able to verbalize EMTALA requirements, stated he is trained annually on EMTALA, and most recently he received EMTALA training within the past 2 weeks. Record reviews of 20 sampled ED patients were selected from the ED control log, based upon sample selection of similar diagnosis and patients transferred to another level of care. The review did not reveal any patients in the sample who did not receive the appropriate medical screening exam (MSE). No record existed for sample patient #21. A visit was made to the receiving facility (a psychiatric facility) for sample patient #21 on 3/26/15 at approximately 9:00 am. The receiving facility was able to confirm that patient #21 was admitted under the provisions of the Florida Baker Act on 3/5/15, by law enforcement, and identified the psychiatric diagnosis of the patient.

Based on review of Capital Regional Medical Center's written self-report of Emergency Medical Treatment and Active Labor Act (EMTALA) violation, interviews with the hospital Risk Manager (RM), Emergency Department (ED) Director, and other ED staff members, and review of the hospital EMTALA policies, the hospital failed to provide Stabilizing Treatment for 1 of 21 patients in the sample (#21). The findings are: The facility submitted to the state survey agency the following potential violation self-report of the Emergency Medical Treatment and Active Labor Act (EMTALA) on 3/18/2015: "On 03/05/2015, at approximately 10:52 a.m., the patient entered the Walk-In entrance of our hospital which provides access to both the Emergency Department (ED) and other areas of the hospital. The patient proceeded to the patient and Visitor Waiting Area to the left of the entry door and then walked toward our Security Officer, who was sitting at the back area of the reception desk. The Security Officer is an off-duty Deputy with the County Sheriffs Office and employed by the contracted Security service to provide security at Capital Regional Medical Center. The reception desk is U-shaped with a Receptionist sitting in the center section. The Receptionist assists those coming through the entrance that may need assistance in initiating the ED (Emergency Department) process or directions to other areas of the facility. The Security Officer was sitting on the back left side of the U-shaped desk where there is a lower desk section for use by visitors or patients in wheelchairs. When the patient went to speak with the Security Officer the patient sat in a chair across from the Security Officer. The patient and Security Officer carried on a conversation for approximately 25 minutes. The Receptionist, when we interviewed her, said she did not see the patient enter the building but later saw him sitting in the chair talking with the Security Officer. She heard the patient say he was in fear for his life and the security guard explained the Baker Act to the patient. In addition, the Receptionist said she heard the patient state that he wanted to leave but she heard the Security Officer say he had to stay at the desk. Security video footage shows that a County Sheriffs Office Deputy entered the ED at 11:25 a.m., and the Security Officer, the patient, and the Deputy walked toward the entrance of the ED. They had a conversation by the entrance to the ED and at approximately 11:33 a.m., the patient exited the ED with the Deputy and the Security Officer. Approximately 30 minutes after the patient left, the Security Officer approached the Charge Nurse and explained that the patient walked up to him at the reception desk, stated that he needed help, someone was trying to kill him and he heard voices in his head. Because of this, the officer called a Sheriff cruiser to come get the patient and take him to a Baker Act Receiving facility." The Baker Act is a Florida Statute designed to protect the rights of persons with mental illnesses, and allows the judicial system, law enforcement, and under certain circumstances, certain medical professionals to have a person involuntarily taken to a psychiatric receiving facility for evaluation and treatment of a suspected psychiatric condition. The facility EMTALA - Florida Medical Screening Examination and Stabilization Policy, effective 3/1/13 was reviewed. The policy states: "an EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and: the individual or representative acting on the individual's behalf requests an examination or treatment for a medical condition, or a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition. The policy continues to state, and provide an example as follows: "the individual arrives on hospital property either in the DED or property other than the DED, and no request is made for evaluation or treatment, but the appearance or behavior of the individual would cause a prudent layperson observer to believe that the individual needed such examination or treatment." On 3/26/15 at approximately 3:25 pm, an interview was conducted with the ED Receptionist. The receptionist stated that on 3/5/15 she was on shift at the reception desk. She heard a man state that somebody was after him and he was in fear for his life (to the security guard). She stated it was pretty busy that day, and she was probably 20 feet away from them. She did not hear what the officer said to him. The officer did not address her at all about the incident. On 3/26/15 at approximately 3:50 pm, an interview with was conducted with the ED Charge Nurse on duty on the day shift on 3/5/15. The charge nurse stated the security officer was at the nursing desk, and informed him that he had "taken care of one patient for him". The charge nurse stated the security officer explained what he had done. The charge nurse stated he sent an email to the ED Director about it, and also did an occurrence report which went to the risk manager the next day. He then stated he discussed it with ED Director. He also stated that the ED does "morning huddles" to talk about previous days events, and to put out new information to staff. Security is not involved in those huddles. The huddles were used to review EMTALA requirements with clinical staff after the event. A handout has been given out to all employees with EMTALA updates. We also have Annual EMTALA training. On 3/27/15 at approximately 12:15am, a telephone interview was conducted with the security officer on duty in the ED on the date of the incident. The officer confirmed that he was on duty that day at his part time security job with the hospital, and that he was a full time county deputy sheriff. The officer stated he was seated when a man entered the reception area. The man sat in a chair for a while, and then got up, and down a couple of times. He stated the man eventually asked him if he could help him. The officer stated he asked the man if he needed to see a doctor, and the man replied "No", he needed his help because people were trying to kill him. The officer further stated the man made comments about the "people" that were in his head and trying to kill him. The officer states he noticed what looked like healed cuts on the man's wrists. When he asked about the cuts, the man replied that he had to cut himself sometimes so the people would go away. The officer stated he called the county sheriff's office dispatch, and asked for a car to be sent to the hospital. The car arrived with 2 other officers. One officer came into the reception area, and after discussing the situation with the officer and the man, it was decided the man was a harm to himself, and he was taken to a local Baker Act receiving facility, under the Florida Baker Act law. The officer stated that he was given a pamphlet about EMTALA upon hire, approximately 2 months ago. He states he honestly just glanced at the pamphlet, not really reading it. He stated that when he saw the man exhibit what he thought was clear suicidal and paranoid behavior, he just did what he would normally do in his role as a county deputy sheriff, and he had the man taken by law enforcement for transport to a psychiatric receiving facility. He only later, after the man was escorted from the building by other officers, informed the charge nurse. That was when he was informed that he had made a mistake, and should not have done that. The officer states he has now been trained, and fully understands the requirements for the hospital when anyone comes to the hospital property, and asks for treatment, or is observed to possibly need treatment. A further review of the hospital written policy reveals a "bold font" paragraph, with the title "Baker Act Patients, which is underlined. The paragraph states: With respect to the provision of emergency services and care to patients who are being involuntarily examined under Chapter 393, Florida Statutes (the "Baker Act"), facility shall adhere to the requirements of Chapter 394, Florida Statutes, regarding patient rights and involuntary examination procedures, regardless of whether facility is designated as a receiving facility under the Baker Act. Facility shall adhere to, and maintain in the Emergency Department, copies of the provisions of the Baker Act which govern Baker Act patient rights and the involuntary examination process. To the extent that the Baker Act conflicts with EMTALA, facility shall comply with EMTALA. At approximately 10:30 am on 3/25/15, and interview was conducted with the facility Risk Manager (RM). The RM confirmed the contents of the written self-report of emergency access violation, including the statements made from the receptionist, and from the security officer on duty at the time. The RM also stated that the security guards are provided by a contracted Security Agency, and the security guards are expected to follow all facility policies. On 3/26/15 at approximately 4:00 pm an interview was conducted with the ED Director. The ED Director stated that during orientation to the facility, all staff, including contracted security guards are provided an EMTALA pamphlet. The pamphlet provides the basic guidelines for compliance with EMTALA requirements, emphasizing stabilizing treatment. Since the incident occurred on 3/5/15, 100% of security officers have been re-trained on EMTALA, and a copy of the EMTALA pamphlet has been placed in a required daily reading book for security officers working in the ED. (The ED Director provided a list of all security employees with signatures attesting to receiving the EMTALA training). The other ED staff, have been required to read the EMTALA pamphlet again, and retake the Electronic EMTALA training prior to 3/30/15. The ED Director was able to account for the completion of the training requirement through an electronic report. While not all ED staff have completed the training, those who have not, have not been back to work since the incident occurred, due to leave of absence, vacation, sick leave, or as needed work status. On 3/27/15 at approximately 10:30 a.m., and interview was conducted with ED registered nurse "A". Nurse "A" was able to verbalize appropriate knowledge of EMTALA requirements, and stated she receives annual training on EMTALA, and also had EMTALA training as recently as one week ago. Record reviews of 20 sampled ED patients were selected from the ED control log, based upon sample selection of similar diagnosis and patients transferred to another level of care. The review did not reveal any patients in the sample who did not receive stabilizing treatment. No record existed for sample patient #21. A visit was made to the receiving facility (a psychiatric facility) for sample patient #21 on 3/26/15 at approximately 9:00 am. The receiving facility was able to confirm that patient #21 was admitted under the provisions of the Florida Baker Act on 3/5/15, by law enforcement, and identified the psychiatric diagnosis of the patient.

Based on review of Capital Regional Medical Center's written self-report of Emergency Medical Treatment and Active Labor Act (EMTALA) violation, interviews with the hospital Risk Manager (RM), Emergency Department (ED) Director, and other ED staff members, and review of the hospital EMTALA policies, the hospital failed to provide an appropriate transfer of a patient with a reported unstable emergency medical condition for 1 of 21 sampled patients (#21). The findings are: The facility EMTALA - Florida Transfer Policy, dated 3/1/13, was reviewed. The policy stated, " Any transfer of an individual with an EMC (emergency medical condition) must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual ' s behalf or by a physician order with the appropriate physician certification as required under EMTALA. " " A transfer will be an appropriate transfer if: " i. The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual ' s health ... ii. The receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer and to provide appropriate medical treatment; iii. The transferring hospital sends the receiving hospital copies of all medical records related to the EMC for which the individual presented that are available at the time of transfer ... iv. The transfer is effected through qualified personnel and transportation equipment as required including the use of necessary and medically appropriate life support measures during the transport. On 3/26/15 at approximately 4:00 pm an interview was conducted with the ED Director. The ED Director stated that during orientation to the facility, all staff, including contracted security guards are provided an EMTALA pamphlet. The pamphlet provides the basic guidelines for compliance with EMTALA requirements, regarding appropriate transfers. Record reviews of 20 sampled ED patients were selected from the ED control log, based upon sample selection of similar diagnosis and patients transferred to another level of care. The review did not reveal any patients in the sample who were inappropriately transferred to another (appropriate) facility for treatment beyond the capacity of the facility. No record existed for sample patient #21. A visit was made to the receiving facility (a psychiatric facility) for sample patient #21 on 3/26/15 at approximately 9:00 am. The receiving facility was able to confirm that patient #21 was admitted under the provisions of the Florida Baker Act on 3/5/15, by law enforcement, and identified the psychiatric diagnosis of the patient.