Based on review of medical records, policies and procedures, and interviews the facility failed to ensure that an appropriate medical screening examination was completed within the capability of the emergency department to include ancillary services routinely available at the hospital ' s Emergency Department to determine whether or not an emergency medical condition existed as evidenced by failing to address the individual ' s pain and elevated blood pressure prior to leaving the hospital for 1 (#3) of 25 sampled patients medical records reviewed. Refer to findings in Tag A 2406.

Based on review of medical records, policies and procedures, and interviews the facility failed to ensure that an appropriate medical screening examination was completed within the capability of the emergency department to include ancillary services routinely available at the hospital 's Emergency Department to determine whether or not an emergency medical condition existed as evidenced by failing to address the individual ' s pain and elevated blood pressure prior to leaving the hospital for 1 (#3) of 25 sampled patients medical records reviewed. Findings: The facility 's policy and procedure titled, " EMTALA-Georgia Medical Screening Examination and Stabilization Policy " , PolicyStat ID: 6, approved 2013 was reviewed. The policy revealed in part, " Statement of Purpose: To establish guidelines for providing appropriate medical screening examinations ( " MSE " ) ...Policy Am EMTALA obligation is triggered when an individual comes to the dedicated emergency department ( " DED " ) and 1. The individual or a representative acting on the individual ' s behalf requests an examination or treatment for a medical condition ...Procedure: 1. When an MSE is Required A hospital must provide an appropriate MSE within the capability of the emergency department including ancillary services routinely available to the DED to determine whether or not an EMC exists. " The facility ' s policy and procedure entitled, "Procedure for Emergency Registration & Admission and ESP (Emergency Services Protocol) Program, Page 8, EFFECTIVE DATE 01/01/2014 was reviewed. Emergency Department Medical Screening Exam (examination) for Qualified Medical Person. The non-emergent patient is identified by the Qualified Medical Person via facility specific designated (e.g. Blue Folders, Lavender Physician T-sheets, etc.). Following the medical screening exam, these patients are routed to registration for upfront collection and registration according to the ED Medical Screening Exam Flow, Scripting and troubleshooting process... The non-emergent patient required to pay the facility assigned QMP maximum deposit. Upon discharge, the ED Discharge Disposition must be " HOME. " ... Non-emergent patients who do not pay the required QMP maximum deposit at time of service may elect to leave the ED to receive care from a family physician or local resource ...Non-emergent patients who pay the required QMP maximum deposit are treated accordingly." Review of the policy entitled " Standards of Triage & Care in the Emergency Department, " last reviewed 10/2014, revealed that level 4 acuity patients included minor back pain, " Pulled something " - muscle spasms; localized back pain (4-7/10). Possible extremity fracture, swollen, hot " joint , tight cast-no neurovascular impairment. Review of patient #3 ' s medical record revealed the patient was an uninsured patient who walked into the ED on 01/04/16 at 6:16 PM with complaints of back pain. The triage nurse #5 (a nurse who assessed a patient to determine in which a severity of the chief complaint and the priority in which a patient will be seen by the provider) noted that the patient was a level 4 (semi-urgent). Documentation the patient was initially with the provider at 6:19 PM and that the patient was placed in an ED room at 6:22 p.m. The triage nurse noted that the patient reported that his/her pain was a 4 on a pain scale of 1 (minimal pain) to 10 (severe pain) and that a level 3 was an acceptable pain level. The nurse noted that the pain was sharp and throbbing and that daily activities aggravated his/her back pain. In addition, the nurse noted that the symptoms had begun at 5:00 p.m. The nurse also noted that the patient had reported similar episodes that had never been evaluated and that the patient reported pain when walking. The nurse noted that the patient ' s temperature, pulse, respirations, and oxygen level were within normal limits. The patient ' s blood pressure was noted to be 157/101 ( Normal Blood Pressure 110-120/60-80). In addition, the nurse noted that the patient was alert and oriented to person place time and situation, moved all extremities, had no paralysis and ambulated independently. The Conditions of Admission and consent for Outpatient Care form was signed by patient #3 on 01/04/16 at 6:13 p.m. Further review revealed that at 7:07 p.m. the patient was discharged and the patient ' s pain intensity was still 4. Review revealed that patient #3 physically left the ED at 7:08 p.m. Documentation revealed that Discharge information was provided for patient #3 but the patient refused. Continued review of the medical record revealed that patient #3 was evaluated by a Physician ' s assistant (PA-#1) on 1/04/16 at 6:19 p.m. and that the PA completed the facility ' s electronic " HPI (History of Present Illness)-Back pain 40 and Under " forms. The PA noted that the patient complained of spontaneous low back pain that had started earlier that morning. The PA also noted that the quality of the pain was " spasms " with no radiation of pain. The PA noted that patient #3 reported that initially the pain had been a 7 on a scale of 1 to 10, but that the pain was now a 3 on a scale of, 1 to 10. The PA noted that the patient denied abdominal pain, fever, inability to walk, incontinence, neurological symptoms, numbness or tingling of the lower extremities. The PA notes indicated that the patient ' s pain increased with movement and was relieved by lying still. In addition, the PA noted that the patient reported that he/she had chronic back pain and that the episode felt like prior episodes. The PA noted that a review of the patient ' s systems were negative with the exception of the low back pain. The PA noted that the patient had no neck, upper back, extremity, or joint pain. The PA noted that the patient had a past history and that the patient ' s medications, allergies, and vital signs were reviewed. The PA noted that patient #3 ' s physical examination revealed the patient was alert and oriented to person, place and time, and that the patient was not in acute distress. In addition, the physical examination included the following: full range of motion of the neck, neurovascular (nerves and blood flow) intact, extremities have full range of motion with equal pulses, movement, and tendon reflexes, back has no vertebral or peri-spinal tenderness and no muscle spasms. In addition, the physical examination revealed that the patient was able to perform a straight leg raise with no findings and that cranial nerves II-XII were intact. The patient also had normal movement deficits and equal reflexes bilaterally. The PA noted that the ESP (Emergency Services Protocol) was complete and the patient was discharged . The PA ' s notes were electronically signed on 01/04/2016 at 7:15 p.m. and were also reviewed and electronically signed by the ED Physician #2 on 01/04/2016 at 8:47 p.m. The electronic record noted that at 6:39 p.m. the PA entered the patient as having a non-urgent medical condition. The Non-Urgent MSE Determination >5 <65 Years of Age was completed by the PA on 01/04/2016. The form noted that the MSE was completed and that immediate medical attention was not necessary because there was no acute symptoms of sufficient severity and no immediate serious impairment or dysfunction of body functions or organs is reasonably expected. This form was also signed by the Registrar #9 on 01/04/2016. The Registrar checked the box noting that the patient had received an MSE and that no Emergency Medical Condition (EMC) was found by the qualified medical personnel (the PA). This box noted that the patient declined further treatment and had left the facility. In addition, in this box the Registrar provided a listing of community resources to the patient for follow-up care for the patient ' s non-emergent medical condition. The triage nurse also signed this form, signifying that the patient received an MSE, was found to have no EMC, that the patient declined further treatment and had left the facility, and that the Registrar had provided a list of Community resources for follow-up of a non-emergent medical condition. The medical record did not contain evidence that any medications or treatment had been administered for patient #3's complaint of pain on 1/4/2016;despite the patient reporting to the provider of prior episodes of pain that were never evaluated prior to this ER visit. The medical record did not contain evidence that the patient's elevated blood pressure had been addressed following triage, or prior to discharging patient #3 on 1/4/2016. The facility failed to ensure that a complete medical screening examination was provided for patient #3 on 1/4/2016. During an interview on 01/13/16 at 4:30 p.m. in the Administrative Board Room, the PA (#1) said that he/she recalled caring for someone who had presented to the ED in a semi truck. The PA reviewed patient #3's medical record and stated the patient did not seem to be in severe pain and that the patient did not trigger any red flags for anything. The PA confirmed that the patient's physical examination had been negative and that the patient had reported that the back pain felt like previous episodes. The PA also confirmed that the nurse documented the patient's pain as a 4 on a scale of 1 to 10. The PA stated the patient told me that the initial pain was a 7 but the pain level was now a 3 on a scale of 1 to 10. The PA explained he/she had not ordered any diagnostic tests because none were needed. The PA stated that after ensuring that the patient did not have an EMC he/she clicked the non-urgent button on the computer which triggered the Registrar to come in and talk with the patient. After the Registrar talks with the patients I am notified if the patient decides to continue treatment. The PA stated no pain medications were ordered because the patient decided not to stay and left the ED voluntarily. The PA stated that if patients decide to stay and continue treatment they agree to pay any insurance co-payment or the hospital's fee. During a telephone interview on 01/14/16 at 1:30 p.m. in the Administrative Board Room, ED physician (#2) stated that since patient #3 was determined by the QMP (Qualified Medical Person) as not having an EMC and declined further treatment that he/she would not have seen the patient. The physician explained that after being evaluated by the mid-level provider all patient's can request to be re-evaluated by a physician but that as far as he/she knew this patient had not asked to be re-valuated by a physician The physician stated he/she had reviewed the PA's (#1) documentation and signed off after determining that the documentation was appropriate. During an interview on 01/14/16 at 8:30 a.m. in the Administrative Board Room, the ED Medical Director (#3) explained that once a provider has screened a patient and determined that the patient does not have an EMC, the provider hits the non-urgent button on the computer screen, and this notifies the Registrar staff that they can now talk with the patient. The Medical Director stated the providers have no way of knowing whether the patient has insurance or any other payer source. The Medical Director stated once the determination is made that the patient has no EMC the patient can elect to stay and pay any co-payment or the hospital's fee of $175.00. In addition, the Medical Director stated that if the patient decides to leave and go elsewhere, the patient has received a triage assessment, been placed in an ED room, and has had a MSE at no charge to the patient. During a telephone interview on 01/14/16 at 1:45 p.m. in the Administrative Board Room, the PA (#4) confirmed that he/she had been in with the triage nurse on 01/04/16 when patient #3 presented to the ED. The PA confirmed that he/she vaguely remembered patient #3 because the patient was driving a semi truck. The PA stated the patient had been ambulatory upon arrival and appeared to have mild discomfort. The PA confirmed that he/she was unaware of the patient's payer source and did not ask the patient. The PA said the patient was triaged and placed in a room to be evaluated by another provider. The PA confirmed that after being seen by the QMP and determined to have no EMC that the Registrar would speak to the patient regarding the patient's options of whether they wished to stay and continue treatment after paying any co-payment or the hospital's fee or declined further treatment and wished to leave. During an interview on 01/14/16 at 10:15 a.m. in the Administrative Board Room, the Registered Nurse (#5) confirmed that he/she was the triage nurse when the patient (#3) presented with complaints of back pain. The nurse explained that he/she remembered that the patient was a semi-truck driver who presented with complaints of back pain. The nurse said that the patient ambulated into the ED with a spouse and that when the patient walked he/she had a painful facial expression. The nurse confirmed that the patient was evaluated by a PA, was determined not to have a EMC, and then seen by a Registrar staff member. The nurse stated he/she observed the patient walk out of the ED and that the patient did look a "little uncomfortable walking". The nurse said that about 50% of the patients who were determined not to have an EMC decided to stay and pay any required co-payments or the facility's require $175.00 for uninsured patients. During an interview on 01/14/16 at 3:00 p.m. in the Administrative Board Room, the Director of the ED (#) confirmed that the facility followed the above QMP process. Medical records were audited to ensure patients who did not have an EMC, and were given the option to continue their treatment, and patients that decided to leave received a community resource list. During interviews on 01/14/16 at 10:50 a.m. and 2:40 p.m. in the Administrative Board Room, the Registrar (#9) and the Director of Patient Access (#10), respectively, both interviewees confirmed that the facility's policy regarding the QMP patient was as follows: --the provider evaluates the patient and determines that there is no EMC, --the provider hits the computer button that signifies that there is no EMC, --a Registrar staff member speaks with the patient and discusses the patient's options of continuing treatment which includes paying any required insurance co-payment or the facility's fee of $175.00 for non-insured patients, and --if the patient decided to leave the patient was to be provided with a community resource list and would not accrue any charges.

Based on review of medical records, transfer center recordings, transfer center log, bed census reports, policies and procedures and staff interviews, the facility failed to accept the transfer from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who required such specialized services capabilities or facilities if the receiving hospital has the capacity to treat 1 (#18) of twenty (#20) patients sampled patients medical records reviewed. Findings include: Review of PolicyStat 9, EMTALA- Transfer Policy, approved and revised 03/2013, revealed that a hospital with specialized capabilities or facilities (including, but not limited to burn units, shock-trauma units, neonatal intensive care units or with respect to rural areas, regional referral centers) shall accept from a transferring hospital an appropriate transfer of an individual with an EMC who requires specialized capabilities if the receiving hospital has the capacity to treat the individual. The transferring hospital must be within the boundaries of the United States. Review of recorded Transfer Center telephone calls from 12/13/15 revealed that physician (MD #9) was contacted by another facility's ER physician on 12/13/15 to request transfer of an [AGE]-year-old patient (#18) with high blood sugar of 696 - (normal range is less than 140 two [2] hours after eating), pneumonia and high blood sodium of 154 (normal range is 135-145) to this facility. After the ER physician provided details on the patient's condition and the treatment rendered, MD #9 (on call physician at Doctors Hospital ) could be heard stating "can't you handle the glucose?" and that he/she did not see a reason for him/her to admit the patient, and that he/she thought the patient could be managed over there. MD #9 could be heard further making treatment suggestions and instructed the ER MD to telephone him/her back if the patient did not improve. The MD further stated that he/she was not going to do anything differently than what the ER MD was doing over there and that was the only reason he/she did not want to take the patient. Further review of the 12/13/15 Transfer Center telephone calls revealed that the transfer center contacted Doctors Hospital Bed Control Supervisor to advise of the physician's transfer request denial. The Bed Control Supervisor could be heard stating "well, that's what we have to go with". Further review of the 12/13/15 Transfer Center telephone calls revealed that the revealed that the transfer center contacted Doctors Hospital facility Administrator on Call to advise of the physician's transfer request denial. After the transfer center provided details of the situation, the Administrator on call could be heard asking "how did they take it?" After the transfer center's response, the Administrator on call stated that he/she thought "that sounds appropriate", and "okay, I agree" (with the denial). The Transfer Center Pre-Admit Sheet dated 12/13/2015 for patient #18 was reviewed. The patient ' s diagnosis #1 was listed as pneumonia, hypernatremia (Elevated Sodium level); History of Present illness: ICU (Intensive Care Unit) Bed unresponsive. Review revealed that the Emergency Department physician from Hospital B called on 12/15/2015 at 10:34 " Spoke to (MD NAME) - " LOOKING TO TRANSFER TO HOSPITALIST. " The section of this form titled " Accepting Services and Provider Service: Pulmonary Critical Care Medicine ...Physician ' s Name (#9) ...Acceptance Status: Denied. Date and time of decision: 12//134/2015 11:04 Explanation: PHYSICIAN REFUSAL...Notes: ...12/13/2015 11:04 DR TO DR-84 YO (year old) NURSING HOME PATIENT HAS HYPERGLYCEMIA IS 698 ON ARRIVAL HYPERNATREMIC IS DNR (Do not resuscitate) IS UNRESPONSIVE ON FEEDING TUBE. PT COULD BE MANAGED OVER THERE HAS PNA (pneumonia), STATED ANTIBIOTICS DOES NOT REQUIRE ANY DIFFERENT CARE THAN ALREADY BEING DONE ...12/13/2015 11:09:CALLED LEFT MESSAGE FOR AOC (administrator on call) ...on denial of patient ...Notes: 12/13/2015 10:46 (House Supervisor) ...ICU GOOD ...12/1/3/2015 11:13:CALLED LEFT MESSAGE-FOR AOC ...ON DENIAL OF PATIENT AND CALLED HOUSE SUPERVISOR. House Supervisor AND ADVISED OF DENIAL OF PT (patient) WHO STATED WOULD STAND BY DRS (doctors) DECISION ...12/13/2015 11:39 AOC ...CALLED BACK. I ADVISED HER OF DENIAL AND THE DRS RESPONSES SHE STATED SHE AGREED WITH DECISION. PLACEMENT ...Placement ... Notes 12/13/2015 10:55: CHECKED ICU BEDS -OK. " Review of the hospital's bed census for the ICU dated 12/13/2015 revealed the hospital census for the unit was 13. The hospital's ICU Bed capacity is 24. Interview with the ER Medical Director on 12/30/15 at 10:40 AM in the conference room revealed an acknowledgement of the transfer denial by MD #9 on patient #18. The ER Medical Director explained that MD #9 may not have believed that the patient needed to go to the ICU (Intensive Care Unit) or may not have known that he/she needed to accept the patient, even if the hospitals provided the same level of care. The ER Medical Director stated "if we have a bed, we have to take them." Review of the hospital ' s bed census verified that on 12/13/2015 the hospital had a bed (capacity) to accept patient #18 on 12/13/2015 when the request was made by the ED physician from the referring hospital. Telephone interview with MD #9 on 12/30/15 at 12:20 PM revealed that he/she recalled the telephone conversation with another facility's ER MD regarding their request to transfer patient #18 to this facility. The MD stated that he/she had not accepted the patient because the patient had pneumonia, high blood sugar, and high sodium, all of which could be managed on a medical floor. MD #9 further explained that the patient had already received antibiotics and intravenous fluids and that he/she would not have consulted with any specialist, such as a pulmonologist or a nephrologist. He/she stated that he/she believed the referring hospital had the capability to provide the necessary services to the patient. MD #9 further stated that he/she had worked as a Hospitalist at this facility for nearly one (1) year, and, believed that he/she had received EMTALA training on hire. Doctors Hospital had the capability to accept patient #18 on 12/13/2015 when the ED physician from Hospital A called and requested a transfer.

Based medical reviews and policies and procedures the facility failed to ensure that an appropriate medical screening examination was provided to the individual ' s presenting signs and symptoms that was within the capability and capacity of the hospital ' s emergency department, including ancillary services routinely available to the emergency department for 1 (#1) of 20 sampled patients medical records reviewed. Findings: The hospital ' s Policy and procedure titled " EMTALA -Georgia Medical Screening Examination and Stabilization Policy " Policy number PolicyStatID : 6, last revised 03/3013, specified in part, " Statement of Purpose: To establish guidelines for providing appropriate medical screening examination (MSE) ...Policy: An EMTALA is triggered when an individual comes to a dedicated emergency department( " DED " ) ...Procedure: ...1. When an MSE is required: A hospital must provide an appropriate MSE within the capability of the hospital ' s emergency department including ancillary services routinely available to the DED, to determine whether or an EMC exists.(i)to any individuals ...who requires such an examination; (ii)an individual who has such a request made on h s or her behalf; or ...a The individual comes to the dedicated emergency department of a hospital and a request is made by the individual ...for examination or treatment for a medical condition, including where: i. The individual requests medication to resolve or provide stabilizing treatment for a medical condition .....Extent of MSE a. Determine if an EMC exists ...b. Definition of MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual ' s presenting signs and symptoms and the capability and capacity of the hospital. " The hospital s policy and procedure titled, "Standards of Triage in the Emergency Department" Original Date 12/96 revised Date: 10/15 was reviewed. The policy specified in part, " Purpose: To provide assessment/reassessment guidelines for initial evaluation, continued monitoring, and/or changes in patient acuity levels according to severity of illness or injury ...Guidelines: All patients presenting to the emergency department room are assessed rapidly to determine the severity of the presenting chief complaint. Acuity is assigned to each patient during the rapid initial assessment ...Definitions: Triage Assessment-The dynamic process of sorting, prioritizing, and assessing the patient is performed by a qualified RN at the time of presentation and before registration ...C. The triage nurse will determine the status of the patient based on the following criteria ...b. Level 2 Triage Category: may include, but not limited to: ...CN (Central Nervous System) Serve headache with high blood pressure, ...altered LOC (Level of Conscious) ... headache ... c. Level 3 Triage Category ... CNS- Headache- severe (mild-moderate distress, pain scale 8-10/10), no LOC vomiting.... II Assessments: ... C. Focused Chief Complaint Assessment/Primary Assessment: 1.) Ongoing Vital signs 2) Ongoing pain Assessment 3) Data pertinent to the clinical presentation/chief complaint 4) documentation of any other complaints 5) Nurse Notes 6) Medications, treatments, and interventions performed on the patient ...III Reassessments/Vital Signs Guidelines A.) Reassessments/Vital Signs guidelines after initiation of the medical screening exam (MSE) are performed by nursing according to acuity ...3. Level (3) Urgent will be performed and documented every hour and more frequently if condition warrants. " The facilities Policy and Procedure titled "Procedure for Emergency Registration & Admission and ESP Program" reference Number: PARA.PP.PTAC.005 Effective 01/01/2014 was reviewed. The policy specified in part, "Emergency Department Medical Screening Exam for Qualified Medical Person...The non-emergent patient by the Qualified Medical Person(QMP)...Non-Emergent patients who do not pay the required QMP maximum deposit at the time of service may elect to leave the ED to receive care from a family physician or local community resource...Non-emergent patients who pay the required QMP maximum deposit are treated accordingly." The medical record for patient #1 was reviewed. Review of the form titled "Emergency Patient Record," revealed that patient #1 (MDS) dated [DATE] at 9:18 p.m. Documentation by the Emergency Department (ED) Nurse specified Patient#1 stated and chief complaint was listed as "Ingestion." Patient #1 ' s ESI (Emergency Severity Index) was listed as " 3/Urgent." Further documentation by the ED nurse revealed in part in the section titled, "Assessments " revealed in part, "Subjective Assessments: " Pt. (patient) states a friend gave her what she thought was a goodie powder and a short time later she states she blacked out and could not remember things." The patient ' s Vital signs were listed as: Blood Pressure 180/110 (normal blood Pressure 120/80); Temperature: 98.0; Respirations: 18; and Oxygen saturation (measurement of oxygen the blood is carrying as a percentage)99%. Documentation by the ED nurse revealed in part,"... 2158 (9:58 PM) Patient Tearful, had headache, states asked for goodie powder, given by roommate sister's boyfriend, Patient Anxious, asked to repeat tem (temperature), the same. C/O (complain/of) neck pain, headache, face, left shoulder, states sinus headache before med (medication). Believes she was given something else. . 10:00 p.m. ... " Presenting Signs and Symptoms: HEADACHE, FACE PAIN, " FEEL FUNNY " ....2205 (10:05 PM) {ED physician name] stated has seen patient, no assault, sexual assault, ...Patient still crying and wants something for pain 2214 (10:14 PM) Patient vomited small amt (amount), food , not paying to be seen, asking for Tylenol for pain, ambulates well, steady gait, escorted to friends room. 22:15 PM (10:15 PM) ...Pain Scale: Numeric Intensity: 7(Pain scale 0-10 with 10 being the highest) ...physically leaves the ED ...22: 35 (10:35 PM) " The ED physician documented in part, " HPI (History of Present Illness) ... Context- related history: Took medication then left. Did drink some alcohol (1 shot) ...Phy (Physical) Exam (examination)- General Med ...General : Alert, oriented X3, cooperative, distress (Mild distress) ...Disposition- ...Clinical Impression ...Substance intoxication. " Review of the form in the medical record entitled, "Doctor's Hospital MSE (Medical Screening Determination) dated 12/13/2015 revealed in part, QMP (Qualified Medical Personnel) " ____MEDICAL SCREENING COMPLETE: Immediate medical attention not necessary, no acute symptoms of sufficient severity ....no immediate serious impairment or dysfunction of body functions or organs is reasonably expected ... Triage Nurse____ patient received medical screening exam. No emergency medical condition found per qualified medical personnel. Patient declined further medical treatment at the facility and has left. Registration provided a listing of community resources to the patient for follow-up care for the patient ' s non-emergent medical condition." Patient #1 left Doctor ' s Hospital and went to Hospital B, another acute care hospital, where the patient was appropriately treated and discharged . The hospital failed to ensure that an appropriate medical screening examination was provided for patient #1 on 12/13/2015 that was within the capability and capacity of the hospital's ED. This was evidenced by the based on the patient's inability to pay for further treatment to include ancillary services (urine drug screen, laboratory test routinely available related to the patients presenting signs of ingestion of unknown powdery substance. The facility triaged patient #1 as a level 3 (Urgent). According to the facility's policy, levels four and five are non-emergent patient. According to the patient ' s complaints of ingestion of an unknown substance as well as loss of consciousness, there was no documentation in the medical record to indicate the patients VS were taken every hour, despite an elevated blood pressure initially, and no vital signs were completed upon discharge from the ED. The patients presenting signs and symptoms of ingestion of an unknown substance as well as reported loss of consciousness the patient should have been triaged as a level 2 as stated in the facility ' s triage policy. There was no re assessments of the patient complaint of pain and no treatment nor interventions were provided for patient #1 on 12/13/2015.

1. Based medical reviews and policies and procedures the facility failed to ensure that an appropriate medical screening examination was provided to the individual's presenting signs and symptoms that was within the capability and capacity of the hospital's emergency department, including ancillary services routinely available to the emergency department for 1 (#1) of 20 sampled patients medical records reviewed. Refer to findings in tag A-246. 2. Based on review of medical records, transfer center recordings, transfer center log, bed census reports, policies and procedures and staff interviews, the facility failed to accept the transfer from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who required such specialized services (pulmonologist) capabilities or facilities if the receiving hospital has the capacity to treat 1 (#18) of twenty (#20) patients sampled patients record reviewed. Refer to findings in Tag A-2411.

Based on review of the facility's policies and procedures, Hospital incident report, Police Officer Case Report, and staff interviews it was determined that the facility failed to follow their policy and procedure by failing to appropriately transfer an individual to another medical facility for 1 (one) individual (#11) of twenty (20) sampled patients who presented to the hospital's emergency department with a psychiatric emergency medical condition. Findings: 1. Review of facility policy entitled EMTALA (Emergency Medical Treatment and Labor Act) - Transfer Policy, number 9, last revised 03/2013, revealed any transfer of an individual with an Emergency Medical Condition (EMC) 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. The policy also revealed the receiving hospital has agreed to accept the individual to provide appropriate medical treatment and that the receiving hospital has available space and qualified personnel for the treatment of an individual. Review of the Physician Certification form revealed an appropriate transfer included but was not limited to the following: --Medical Condition/diagnosis, --Reason for transfer,--Risks and benefits of the transfer, --Mode/support during transfer as determined by physician, --Receiving facility and individual, --Accompanying documentation,--Patient consent to medically indicated transfer or patient request for transfer. 3. The facility's incident report regarding patient #11 was reviewed. The incident report created on 10/7/2015 at 2:15 p.m. revealed in part, "At approximately 1243. Chief_____ and myself responded to an assistance call to ER (emergency room ) Canopy. Once on the scene I observed an unknown_______ female with small child refusing to exit two visitors vehicle stating that she wanted to go to the VA hospital for her treatment. After continued attempts to get the unknown female out of the vehicle. ____ County Officer was called to assist with dealing with (Patient #11).______County Officer arrived on the scene to speak with (Patient #11) at 1250, getting her to exit the vehicle. (Patient #11) was transported by ____ County Officer to the VA as requested." 4. Review of the ________ County Sheriff's Office case report dated 09/28/2015 revealed the officers were dispatched to Doctors Hospital in reference to a disturbance/nuisance. The officer noted that he/she transported the individual and her baby to the Veterans' Administration Hospital and advised the receiving hospital staff that during transport the individual said that the voices in her head were saying they were going to kill her. INTERVIEWS 1. During an interview on 10/06/2015 at 3:40 p.m. in the Board Room, the Security Lieutenant (#8) stated he/she remembered the episode on 09/28/2015 and that the female had been holding her baby. The Lieutenant explained that the individual was in the back seat of a car at the ED entrance. The Lieutenant said he/she spoke with the driver and was informed that the driver had picked the individual up when the individual was observed walking down the road. The Lieutenant stated the driver informed him/her that although the individual (Patient #11) wanted to go to the Veterans' Hospital the driver had brought the individual to Doctors Hospital. The Lieutenant explained that the individual did not want to get out of the car and that the ______ County Sheriff's Office was notified. The Lieutenant said that once the Sheriff's Officer and nurse arrived that he/she had left the scene and did not know where the individual went. 2. During a telephone interview on 10/07/2015 at 12:10 p.m. in the Board Room, the Chief Security Guard stated he remembered the episode regarding two (2) women driving up to the ED entrance with a female carrying a baby in the back seat. The Chief said that the driver's daughter informed him/her that they had observed the female walking down the road carrying a baby and that they offered the individual a ride. The Chief stated the two (2) ladies reported that they were concerned because the female was twitching and had informed them that she was a veteran. The Chief explained that the female refused to get out of the car and that the two (2) ladies wanted her out of their car and reported that they were not taking the female to another facility because they feared for their safety. The Chief said he/she was concerned for the baby and that the local Sheriff's Office was notified so that they could assist with getting the female out of the car. The Chief said that the ED Nurse Manager arrived and that the Nurse Manager and the Sheriff's Officer got the female out of the car and took her into the ED. The Chief said that approximately five (5) to ten (10) minutes later the female was escorted out of the hospital by the Sheriff's Officer and they were taking her to the Veterans' Administration Hospital. The Chief stated he/she stayed outside talking with the driver and never went inside the hospital with the female. 3. During an interview on 10/06/2015 at 1:25 p.m. in the Board Room, the ED Nurse Manager (#3) confirmed that on 09/28/2015 a female (patient #11) was brought to the ED entrance by two ladies. The Manager explained that the facility's Security Guards responded and that the female did not want to get out of the car. The Manager said that the local police department was then notified. The Manager stated the female finally got out of the car and entered the ED. The Manager said he/she asked the female if she had any medical problems or needed to be seen in the ED and that the female stated no. The Manager further explained that the female reported that she wanted to go to the Veterans' Administration Hospital. The Manager explained that the ED physician (#4) talked with the individual and that the individual continued to refuse treatment and was requesting to go to the Veterans' Administration Hospital. The Manager said that after the physician spoke with the individual the individual said she did not have a ride to the other facility and that the local Sheriff's Officer offered to give the patient a ride to the Veterans' Administration Hospital. 4. During an interview on 10/06/2015 at 1:40 p.m., the ED physician (#4) stated he/she had been asked to see a female who had been walking and was picked-up by two (2) ladies and brought to the ED entrance. The physician stated the individual did not want to be treated at Doctors Hospital and that the individual stated she wanted to go to the Veterans' Administration Hospital where she had received psychiatric treatment and her medications. The physician said the individual ended up in the ED and that he/she spoke with the individual and tried to offer her treatment. The physician confirmed that the individual was holding her baby at the time. The physician said the female was adamant that she did not want to receive treatment at Doctors Hospital. The physician said the individual was alert to person and place and that the Sheriff's Officer offered to drive the patient to the Veterans' Administration Hospital. The facility staff was well aware that patient #11 was being transferred to VAH on 9/28/2015 and failed to notify the receiving hospital to obtain agreement and acceptance of the patient in order to provide appropriate medical treatment, and failing to ensure the receiving hospital (VAH) had available space and qualified personnel for treatment of the patient. The facility also failed to provide documentation that a written certification for transfer form was completed by the ED physician for patient #11. As this resulted in an inappropriate transfer for patient #11 on 9/28/2015.

Based on review of the facility's computer query, Emergency Department Logs,Medical Staff Bylaws, Medical Staff Rules and Regulations, facility policies, medical records, Progress Note physician statement,on-call schedules, incident report, credential files, County Sheriff Office case report, and interviews with the hospital staff , and the County Sheriff Officer, it was determined that the facility failed to ensure compliance with CFR 489.24, for one (1) individual (Patient #11) of twenty (20) sampled patients. Findings: Cross refer to A2406 as it relates to failure to provide an appropriate Medical Screening Exam(MSE). Cross refer to A2407 as it relates to failure to provide appropriate stabilizing treatment. Cross refer to A2409 as it relates to failure to ensure that all transfers are appropriate.

Based on review of the facility's policies, computer query, and staff interviews, it was determined that the facility failed to maintain medical records and other records related to individuals transferred to or from the hospital when a request was made on the individuals behalf for an examination and treatment of a medical condition for one (1) individual (#11) of twenty (20) sampled patients presenting to the hospital's emergency department.. Findings: Review of the facility's policy entitled General Policies - Emergency Department (ED) no policy number, last revised 01/2015, revealed medical records are maintained on all patients presented or presenting themselves for treatment. On 10/06/2015, a computer query using the patient's name, date of birth, and date of event revealed there was no documented evidence that a medical record was generated for Patient (#11) who (MDS) dated [DATE]. During an interview on 10/06/2015 at 1:25 p.m. in the Board Room, the ED Nurse Manager confirmed that on 09/28/2015 a female (patient #11) was brought to the ED entrance by two ladies. The Manager explained that the facility's Security Guards responded and that the female did not want to get out of the car. The Manager said that the local police department was then notified. The Manager stated the female finally got out of the car and entered the ED. The Manager said he/she asked the female if she had any medical problems or needed to be seen in the ED and that the female stated no. The Manager further explained that the female reported that she wanted to go to the Veterans' Administration Hospital. The Manager explained that the ED physician (#4) talked with Patient #11,the patient to refuse treatment and was requesting to go to the Veterans' Administration Hospital. The Manager said that after the physician spoke with Patient (#11), the patient said that she did not have a ride to the other facility. The Manager also stated that the local Sheriff Officer from the ____________County Sheriff Office offered to give the patient a ride to the Veterans' Administration Hospital. The Manager confirmed that a medical record should have been generated for Patient #11 on 9/28/2015. An interview was conducted on 10/06/2015 at 1:40 p.m. with the ED physician (#4) who was present in the ED when patient #11 arrived on 9/28/2015. The physician said he/she did not document the findings because the female was not entered into the system. A telephone interview was conducted on 10/07/2015 at 12:10 p.m. in the Board Room, with the Chief Security Guard. The Chief stated that he/she asked the Nurse Manager if there was any information regarding the female and was told there was no information because the patient was never entered into the system.

Based on review of the facility's policies, Central Log, and staff interview, it was determined that the facility failed maintain a central log on one (1) individual (#11) brought to the hospital's Emergency Department by 2 prudent laypersons seeking assistance and whether he or she refused treatment or was refused treatment, transferred, stabilized, and treated or discharged for one (1) (#11) of twenty (20) sampled patients entered into the Central Log. Findings: Review of the facility's policy entitled EMTALA (Emergency Medical Treatment and Labor Act): Central Log Policy, number 10, last revised 05/2015, revealed 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 (MSE) 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 . Review of the facility's Central Log from April 01, 2015 through October 6, 2015 revealed there was no documented evidence of patient (#11) being entered into the Central Log on 09/28/2015. An interview was conducted on 10/06/2015 at 1:25 p.m. in the Board Room with the ED Nurse Manager. The Manager confirmed that patient (#11) should have been entered into the Central Log. The hospital failed to ensure that their Central Log policy and procedure was followed as evidenced by failing to maintain a Central Log on Patient #11 who was brought the hospital campus on 9/28/2015 by two (2) prudent laypersons because of her behavior and appearance believed that she needed examination and treatment.

2406 Based on review of a medical records, Medical Staff Bylaws, Medical Staff Rules and Regulations, facility's policies, Sheriff's Office Case Report, physician's progress note statement, and On-call schedules, Physician credentialing file, staff and Sheriff's Officer interviews, it was determined that the facility failed to ensure one (1) individual (#11) of twenty (20) sampled patients received an appropriate Medical Screening Examination (MSE) that was within the capability of the hospital's emergency department to determine whether or an emergency medical condition existed for an individual (#11) who was found by 2 prudent laypersons walking the highway with an unsteady gait, twitching and carrying a young child. Findings: 1. Review of the Medical Staff Bylaws, and Medical Staff Rules and Regulations, adopted by the Medical Staff and Approved by the Board on 04/22/2014, revealed MSE(s) within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition (EMC). Qualified medical personnel who can perform MSE(s) within applicable Hospital policies and procedures are defined as: a. Emergency Department: 1. members of the Medical Staff with clinical privileges in Emergency Medicine; 2. other Active Staff members; and 3. appropriately credentialed allied health professionals. 2. Review of the facility's policy entitled EMTALA (Emergency Medical Treatment and Labor Act) - Georgia Medical Screening Examination and Stabilization Policy, number 6, last revised 03/2013, revealed an EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and: 1. the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition, or 2. 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 Medical Screening Examination (MSE) must be completed by an individual (i) qualified to perform such an examination to determine whether an emergency medical condition (EMC) exists. The procedure was as follows: 1. An MSE is required when: a. The individual comes to a DED of a hospital and a request is made by the individual or on the individual's behalf for examination or treatment for a medical condition. .. Extent of the MSE (Medical Screening Examination) a. Determine if an EMC exists. The hospital must perform am MSE to determine if an EMC exists ...Definition of MSE. An MSE is the process required to reach within clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The Medical Screening examination must be appropriate to the patients presenting signs and symptoms and the capability and capacity of the hospital. " 2. The " September : Doctor's Hospital Psychiatry " on-call schedule was reviewed. The review revealed that an on-all psychiatrist was on-call on 09/28/2015 when Patient #11 presented to the ED, and a request was made on the patients behalf by two prudent laypersons for an examination. 3. Review of the ______ County Sheriff's Office case report dated 09/28/2015 revealed in part, the officers were dispatched to Doctors Hospital in reference to a disturbance/nuisance. The report noted that upon arrival, the officer spoke with the driver that drove the individual to the ED entrance and was informed that the driver observed the individual walking and carrying a small child. The report noted that the driver reportedly made the decision to take the individual to Doctors Hospital because the individual had an unsteady gate ({sic}-gait), was fidgeting, making jerking motions, and informing the driver that she had post-traumatic stress disorder and several other issues. The officer noted that upon arrival, the individual refused to exit the car but eventually entered the ED and was taken to a room for an assessment. The officer noted that the individual was advised by staff at Doctors that due to the individual's lack of insurance coverage the individual would be better served at the Veterans' Administration Hospital. 4. The medical record for Patient #11 was obtained from the Veteran's Administration Hospital for review. Review of the medical record revealed that the patient arrived at the VAH on 9/29/2015 at 1:48 p.m. The Emergency Department (ED) physician documented the patient's chief complain as "Paranoid" (Mental illness-being suspicious, irrational obsessive distrust of others). The section entitled "History of Present illness" the Physician documented in part, "Pt (patient) was found wandering along a street reportedly hearing voices and responding to them. Per deputy pt was seen briefly at Doctors Hospital briefly and was sent here for eval (evaluation). Pt states that she is afraid that we are going to take out my heart and also take away her child which she is caring for currently ...Physical Exam (examination) Gen (general): agitated...Psychiatric: paranoid, pressured speech. No SI/HI (Suicidal Ideation- thoughts of wanting to kill oneself/Homicidal Ideation-thoughts of harming others), or AVH (auditory visual hallucinations). The Physician also documented that patient #11 attempted to elope from the VAH during workup. Patient #11 then required security restraint and was given Ativan (medication used to treat anxiety) intramuscularly. The patient was then placed on a 1013 ( a classification for a patient needing emergent in-patient mental health treatment) order. The physician further documented that Patient #11 was to be transferred to an outside facility for further care. The Social Worker documented that patient #11 attempted to elope from the Emergency Department with her baby in her arms. The VA(Veterans Administration ) police and 2 ED physicians, multiple nurses and the Social Worker were involved in patient #11's and her baby's safety. Documentation by the Social Worker revealed in part, "Veteran stated "Don't kill me" , " Please don't shoot me!" the veteran was calmed down and brought back into the ED. Further documentation by the Social Worker revealed that after the patient was brought back into the ED a nurse took the baby to another part of the ED where she could be evaluated further. The Social Worker also documented that the Department of Family and Children Services (DFCS) was called and notified of the situation related to patient #11's child. The DFCS worker contacted the local courts and the child was placed in temporary custody of the court, until patient #11's mother could make arrangements to come in and care for the child. Patient #11 was accepted for in-patient psychiatric care at a Behavioral Health Center. 5. The Progress Notes dated 10/6/2015 and provided by physician (#4) on 10/06/15 revealed the female's (#11) "1350 (1:50 p.m.)Visit date 9/28/2015" The physician noted that the patient's history of present illness was as follows: female brought to hospital against her will by two (2) bystanders who picked the female up when she was observed walking to get to the Veterans' Administration Hospital. The female arrived at Doctors Hospital and was asked to come into a room for an evaluation. The female initially refused but eventually was brought into the ED. Female (#11) reported that she does not want to be here and wants to go to the Veterans' Administration Hospital. The female stated she needed a refill on her medications and denies complaints. Specifically, denies suicidal/homicidal ideations, hallucinations, or delusions. She denies fever, vomiting, diarrhea, headache, numbness, tingling, weakness, trauma, rashes, upper respiratory infections, or urinary tract infection symptoms. Review of systems was negative as stated above. Past medical history was reported as psychiatric issues. Past surgical history is unknown. Physical examination findings were within normal limits and vital signs were refused. Female was alert and oriented to person, place and time. The female's mood was normal. The physician documented the Action/Plan in part, "Patient #11's last name of right refuses all care at Doctors Hospital." She (#11) had no sign of an EMC at this time. She refuses all care here and wishes to go to the Veterans' Administration Hospital. She agrees to go with the Sheriff's Officer for transport to the Veterans' Administration Hospital. She cannot be further treated "at Doctors" against her will. The physician documented patient #11's name and date of birth on the bottom of the progress note. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that an appropriate medical screening examination was provided for patient #11 on 9/28/2015 when 2 prudent laypersons observers concluded that patient #11's behavior walking along a highway with a child (unsteady gait and twitching) requested and needed an examination and treatment of an identified emergency medical condition. There was no documentation in the progress note to indicate with this patient s presenting signs and symptoms that the psychiatrist on-call was called to evaluate the patient. After Patient #11 was taken from Doctor's Hospital via the county police officer it was determined that she had an emergency psychiatric condition. 6. Review of two (2) of two (2) credential files revealed documented evidence of all required facility data. Physician #4 had EMTALA training in 08/2008 and physician #5 had EMTALA training in 03/2012. INTERVIEWS 1. During a telephone interview on 10/07/2015 at 12:10 p.m. in the Board Room, the Chief Security Guard stated he remembered the episode regarding two (2) women driving up to the ED entrance with a female carrying a baby in the back seat. The Chief said that the driver's daughter informed him/her that they had observed the female walking down the road carrying a baby and that they offered the individual a ride. The Chief stated the two (2) ladies reported that they were concerned because the female was twitching and had informed them that she was a veteran. The Chief explained that the female refused to get out of the car and that the two (2) ladies wanted her out of their car and reported that they were not taking the female to another facility because they feared for their safety. The Chief said he/she was concerned for the baby and that the local Sheriff's Office was notified so that they could assist with getting the female out of the car. The Chief said that the ED Nurse Manager arrived, and that the Nurse Manager and the Sheriff's Officer got the female out of the car and took her into the ED. The Chief said that approximately five (5) to ten (10) minutes later, the female was escorted out of the hospital by the Sheriff's Officer, and they were taking her to the Veterans' Administration Hospital. The Chief stated he/she stayed outside talking with the driver and never went inside the hospital with the female. 2. During an interview on 10/06/2015 at 1:25 p.m. in the Board Room, the ED Nurse Manager (#3) confirmed that on 09/28/2015 a female (patient #11) was brought to the ED entrance by two ladies. The Manager explained that the facility's Security Guards responded and that the female did not want to get out of the car. The Manager said that the local police department was then notified. The Manager stated the female finally got out of the car and entered the ED. The Manager said he/she asked the female if she had any medical problems or needed to be seen in the ED and that the female stated no. The Manager further explained that the female reported that she wanted to go to the Veterans' Administration Hospital. The Manager explained that the ED physician (#4) talked with the individual and that the individual continued to refuse treatment and was requesting to go to the Veterans' Administration Hospital. The Manager said that after the physician spoke with the individual the individual said she did not have a ride to the other facility and that the local Sheriff's Officer offered to give the patient a ride to the Veterans' Administration Hospital. 3. During an interview on 10/06/2015 at 1:40 p.m., the ED physician (#4) stated he/she had been asked to see a female who had been walking and was picked-up by two (2) ladies and brought to the ED entrance. The physician stated the individual did not want to be treated at Doctors Hospital and that the individual stated she wanted to go to the Veterans' Administration Hospital where she had received psychiatric treatment and her medications. The physician said the individual ended up in the ED and that he/she spoke with the individual and tried to offer her treatment. The physician confirmed that the individual was holding her baby at the time. The physician explained that he/she asked the female if he/she could examine her and that the female replied no, I want to go to the Veterans' Administration Hospital. The physician said the female finally got on the examination bed, and that he/she did a mental evaluation of the female. The physician said the female was adamant that she did not want to receive treatment at Doctors Hospital. The physician said the individual was alert to person and place and that the Sheriff's Officer offered to drive the patient to the Veterans' Administration Hospital so that the patient could get her medications refilled. The physician said he/she even offered to refill the female's medications and that the female had refused. 4. During an interview on 10/07/2015 at 9:15 a.m., the Corporal (#9) with the _______ County Sheriff's Office stated he/she had been informed by his/her supervisor not to talk with the surveyors. The officer did confirm that he/she and two (2) other officers were present when the ED physician examined patient #11. The facility failed to ensure that their Medical Staff by Laws and Medical Staff Rules and Regulations and the facility ' s EMTALA policy and procedures were followed as evidenced by failing to provide an appropriate medical screening examination that was within the capability (medical clearance, psychiatric evaluation,1013'd, laboratory tests, and appropriate care of the child that presented with patient #11) of the hospital when requested by 2 prudent laypersons that observed and concluded from Patient #11's behavior on 9/28/2015 needed an examination to determine the presence of an emergency medical condition.

Based on review of the facility's policies and procedures, on call schedules, Physician Progress note, medical record and staff interviews, it was determined that the facility failed to provide stabilizing treatment that was within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for an individual that was found wandering the highway with a child for one (1) individual (Patient #11) of twenty (20) sampled patients. Findings: 1. Review of the facility's policy entitled EMTALA (Emergency Medical Treatment and Labor Act) - Georgia Medical Screening Examination and Stabilization Policy, number 6, last revised 03/2013, revealed an EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) ...1. An MSE is required when: a. the individual comes to a DED of a hospital and a request is made by the individual or on the individual's behalf for examination or treatment for a medical condition. This policy noted that if an emergency medical condition (EMC) is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer as defined by and required by EMTALA. 2. The "September : Doctor's Hospital Psychiatry" on-call schedule was reviewed. The review revealed that an on-all psychiatrist was on-call on 09/28/2015 when Patient #11 presented to the ED, and a request was made on her behalf by 2 prudent laypersons for treatment of a medical examination. 3. The medical record for Patient #11 was obtained from the Veteran ' s Administration Hospital for review. Review of the medical record revealed that the patient arrived at the VAH on 9/28/2015 at 1:48 p.m. The Emergency Department (ED) physician documented the patient s chief complain as "Paranoid " (Mental illness-being suspicious, irrational obsessive distrust of others). The section entitled " History of Present illness " the Physician documented in part, "Pt (patient) was found wandering along a street reportedly hearing voices and responding to them. Per deputy pt was seen briefly at Doctors Hospital briefly and was sent here for eval (evaluation). Pt states that she is afraid that we are going to take out my heart and also take away her child which she is caring for currently ...Physical Exam (examination) Gen (general): agitated...Psychiatric: paranoid, pressured speech. No SI/HI (Suicidal Ideations/Homicidal Ideations), or AVH (auditory visual hallucinations). The Physician also documented that patient #11 attempted to elope from the VAH during workup. Patient #11 then required security restraint and was given Ativan (medication used to treat anxiety) intramuscularly. The patient was then placed on a 1013 order. The physician further documented that Patient #11 was to be transferred to an outside facility for further care. The Social Worker documented that patient #11 attempted to elope from the Emergency Department with her baby in her arms. The VA(Veterans Administration ) police and 2 ED physicians, multiple nurses and the Social Worker were involved in patient #11's and her baby's safety. Documentation by the Social Worker revealed in part, " Veteran stated " Don't kill me", " Please don't shoot me!" the veteran was calmed down and brought back into the ED. Further documentation by the Social Worker revealed that after the patient was brought back into the ED a nurse took the baby to another part of the ED where she could be evaluated further. The Social Worker also documented that the Department of Family and Children Services (DFCS) was called and notified of the situation related to patient #11's child. The DFCS worker contacted the local courts and the child was placed in temporary custody of the court,until patient #11'++---s mother could make arrangements to come in and care for the child. Patient #11 was accepted for in-patient psychiatric care at a Behavioral Health Center. 4. The Progress Notes dated 10/6/2015 and provided by physician (#4) on 10/06/15 revealed the female's (#11) "1350 Visit date 9/28/2015." The physician noted that the patient's history of present illness was as follows: female brought to hospital against her will by two (2) bystanders who picked the female up when she was observed walking to get to the Veterans' Administration Hospital. The female arrived at Doctors Hospital and was asked to come into a room for an evaluation. The female initially refused but eventually was brought into the ED. Female (#11) reported that she does not want to be here and wants to go to the Veterans' Administration Hospital. The female stated she needed a refill on her medications and denies complaints. Specifically, denies suicidal/homicidal ideations, hallucinations, or delusions. She denies fever, vomiting, diarrhea, headache, numbness, tingling, weakness, trauma, rashes, upper respiratory infections, or urinary tract infection symptoms. Review of systems was negative as stated above. Past medical history was reported as psychiatric issues. Past surgical history is unknown. Physical examination findings were within normal limits and vital signs were refused. Female was alert and oriented to person, place and time. The female's mood was normal. The physician documented the Action/Plan in part, "Patient #11's last name of right refuses all care at Doctors Hospital " She (#11) had no sign of an EMC at this time. She refuses all care here and wishes to go to the Veterans' Administration Hospital. She agrees to go with the Sheriff's Officer for transport to the Veterans' Administration Hospital. She cannot be further treated " at Doctors " against her will. INTERVIEWS 1. During an interview on 10/06/2015 at 1:25 p.m. in the Board Room, the ED Nurse Manager (#3) confirmed that on 09/28/2015 a female (patient #11) was brought to the ED entrance by two ladies. The Manager explained that the facility's Security Guards responded and that the female did not want to get out of the car. The Manager said that the local police department was then notified. The Manager stated the female finally got out of the car and entered the ED. The Manager said he/she asked the female if she had any medical problems or needed to be seen in the ED and that the female stated no. The Manager further explained that the female reported that she wanted to go to the Veterans' Administration Hospital. The Manager explained that the ED physician (#4) talked with the individual and that the individual continued to refuse treatment and was requesting to go to the Veterans' Administration Hospital. The Manager said that after the physician spoke with the individual the individual said she did not have a ride to the other facility and that the local Sheriff's Officer offered to give the patient a ride to the Veterans' Administration Hospital. 2. During an interview on 10/06/2015 at 1:40 p.m., the ED physician (#4) stated he/she had been asked to see a female who had been walking and was picked-up by two (2) ladies and brought to the ED entrance. The physician stated the individual did not want to be treated at Doctors Hospital and that the individual stated she wanted to go to the Veterans' Administration Hospital where she had received psychiatric treatment and her medications. The physician said the individual ended up in the ED and that he/she spoke with the individual and tried to offer her treatment. The physician confirmed that the individual was holding her baby at the time. The physician said the female finally got on the examination bed and that he/she did a mental evaluation of the female. The physician said he/she did not document the findings because the female was not entered into the system. The physician said the female was adamant that she did not want to receive treatment at Doctors Hospital. The physician said the individual was alert to person and place and that the Sheriff's Officer offered to drive the patient to the Veterans' Administration Hospital so that the patient could get her medications refilled. The physician said he/she even offered to refill the female's medications and that the female had refused. The facility failed to ensure that their stabilization policy and procedure was followed as evidenced by failing to provide stabilizing treatment as required to patient #11 when she and her were brought to Doctor's Hospital's on 9/28/2015 by 2 prudent laypersons seeking treatment for a medical condition.

Based on reviews of medical records and the hospital's policies and procedures the hospital failed to explain the risks and benefits of refusal for further treatment for 1 (#2) of (twenty) 20 sampled patients who presented to the emergency department. Findings: The facility's EMTALA policy and procedure, PolicyStat ID: 20, Original: 08/2008, Approved: 05/2015 was reviewed. Review of the section of the policy titled " Refusal to Consent to Treatment " page 11 of 13 revealed in part, " a. Written Refusal-Partial Refusal of Care or Against Medical Advice. If a Physician or QMP (Qualified Medical Personnel) has begun the medical screening examination or any stabilizing treatment and an individual refuses to consent to a test, examination or treatment or refuses any further care and is determined to leave against medical advice, after being informed of the risks and benefits and the hospital's obligation under EMTALA (Emergency Medical Treatment and Labor Act), reasonable attempts shall be made to obtain a written refusal to consent to examination or treatment using the form provided for that purpose or document the individual's refusal to sign the Partial Refusal of Care or the Against Medical Advice Form ...The medical record must contain a description of the screening and the examination, treatment , or both if applicable, that was refused by or on behalf of the individual." Review of the "Emergency Patient Record" revealed that Patient #2 (MDS) dated [DATE] at 3:10 a.m. The emergency department (ED) documented the"Subjective Assessment: Pt (patient) punched wall. WENT TO____ (acute care hospital name) DX (diagnosed ) WITH OPEN FX (fracture) R (right) HAND. ____ (acute care hospital name) WANTED TO TRANSFER PT. PT WALKED OUT AND CAME HERE. " The patient ' s Chief Complaint was " Extremity Pain/Injury " . Patient #2 ' s Triage level was " ESI (Emergency severity Level) 3/Urgent. " Documentation by the ED nurse revealed the extremity assessment included the mechanism of injury was blunt trauma, the presenting signs and symptoms was edema at injury, extremity discomfort, and decreased range of motion of the left hand. The patient's onset of symptoms was 6/14/2015 at 10:00 p.m. Further review revealed that on 6/15/2015 at 3:38 a.m., an x-ray of the left had was ordered by the ED physician. The disposition of the patient was documented by the ED nurse as, Disposition Category: [Refused Treatment] discharged ....Emergency Notes ...6/15/2015 0351 ...THE PATIENT VOLUNTARILY DEPARTS AT THIS TIME. THE PATIENT WAS MAKING COPULATORY REMARKS AND EXTENDING THE THIRD DIGIT OF HIS RIGHT HAND TOWARD THE NURSING STAFF AS HE WALKED PAST THE NURSING STATION. " The Emergency Provider Report dated 6/15/2015 was reviewed. Documentation by the Physician Assistant (PA) revealed that patient #2 -was seen at 3: 20 a.m. The PA documented the patient ' s chief complaint was " hand injury. " The Physical Examination revealed in part, " Hand: Normal pulse, no [DIAGNOSES REDACTED], normal tendon function, swelling (DISTAL 5TH METACARPAL), abrasion ....Neurologic: No motor deficits, no sensory deficits. Disposition: Extremity Inj (injury) Upper Clinical Impression: HAND CONTUSION/HAND PAIN) (Disposition ...Screened and discharged . " The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure there was documentation in the medical record to indicate a discussion of the risks and benefits of further treatment (x-ray) and/or a description of the treatment that was refused by patient #2 on 6/15/2015.

Based on reviews of medical records and the hospital's policies and procedures the hospital failed to explain the risks and benefits of refusal for further treatment for 1 (#2) of (twenty) 20 sampled patients who presented to the emergency department. Refer to findings in Tag 2407.