Based on review of documents, policies, medical records, the hospital failed to provide within its capabilities and capacity, including the services of an on-call psychiatrist, appropriate stabilizing treatment to an individual with a psychiatric emergency (Patient #2) who presented to the ED requesting psychiatric care and services, out of 12 cases selected for review. The ED nursing director identified an average daily census of behavioral/psych patients of approximately 2 patients. The Behavioral Medicine Unit nursing director identified an average daily census of approximately 8 patients. The hospital failed to provide within its capabilities and capacity, including the services of the on-call psychiatrist, appropriate stabilizing treatment to an individual (Patient #2) with a psychiatric emergency. The ED staff contacted the on-call psychiatrist multiple times and no action was taken when the on-call psychiatrist failed to respond. Findings include: 1. Review of the hospital policy titled, "Examination of Emergency Patient and Hospital Transfers" effective date 10/26/16, revealed the following in part, "The hospital will provide a medical screening examination to anyone who presents to the hospital...and who requests an examination or treatment...the medical screening examination follows the clinical guidelines for appropriate care and may only be performed by a physician of Behavioral Medical Unit Associate Registered Nurse Practitioner (ARNP).. included the following conditions: depression with feelings of suicidal hopelessness, delusions, severe insomnia, and helplessness, history of recent suicide attempt or suicidal ideation...impaired reality testing accompanied by disordered behavior (psychotic)...stability - The degree to which one can be assured within reasonable medical probability that no deterioration is likely to occur from any remaining differential diagnosis...no patient shall be arbitrarily transferred to another hospital. Patient/family wishes are also considered when making the transfer." 2. Further review of the hospitals "Medical Staff Bylaws" revealed, "Emergency Department Policy"...the physician will comply with all hospital and medical staff bylaws, rules and regulations...On call Physician Coverage....the on call schedule covers only the patients in the Emergency Department...determination as to Specialist coverage is based on physician experience...and privileging status." Refer to A 2407 for additional information concerning the medical/psychological screening examination of Patients #2.

Based on review of hospital documents, policies, medical records, and staff interviews, the hospital failed to ensure Patient #2 received further examination and stabilizing treatment for his emergency medical/psychiatric condition within the capabilities and capacity prior to transfer to a psychiatric hospital with the same capabilities and capacity. The revisit involved review of the Emergency Department (ED) medical records for 12 sampled patients who presented to the ED for an emergency medical condition from September 21, 2016 to October 24, 2016. Failure to ensure Patient #2 received further examination and stabilizing treatment within the scope of services available at St. Anthony Regional Hospital placed the patient diagnosed with delusional disorders and paranoia at risk harm and delayed treatment of Patient #2's emergency medical/psychiatric condition. Findings include: Review of the closed medical record showed Patient #2 presented to the ED (Emergency Department) accompanied by police on 10/3/16 at 9:02 PM complaining of psychological disorders, Nursing staff documented the patient was a level 4 and immediately implemented 15 minute safety checks, donned the patient in paper scrubs, and completed a mental health assessment. ED Physician P examined the patient on 10/3/16 at 9:09 PM and documented the patient had paranoid ideation and visual hallucinations and was afraid someone was going to harm him. Further documentation showed that ED Physician P diagnosed patient # 2 with high blood pressure (hypertension), psychoactive substance abuse and unspecified withdrawal. At 9:01 pm patient # 2's blood pressure was recorded at 174/118 (normal 120/80). On 10/3/16 at 9:09 PM, nursing staff documented the patient was anxious and compulsive, hearing voices, felt like people are "messing with him", complained of delusions and hallucinations, and altered sleeping habits. The patient stated a recent diagnosis of schizophrenia and bipolar disorder, however had not been started on any medication. The patient was cooperative with the assessment, however stated having a hard time trusting anyone right now. ED Physician P documented on 10/3/16 at 9:40 PM the patient agreed to admission however at 9:45 PM Patient #2 decided not to stay and signed AMA (Against Medical Advice) paperwork. Physician P documented Patient #2 was provided with a local mental health area number and was able to understand the instructions. The medical record did not contain any evidence that the risks to the patient at the time of his refusal to stay for treatment were explained or identified what the risks were, or any evidence indicating staff attempted to keep the patient from leaving prior to stabilization of his emergency medical condition. The medical record contained multiple entries indicating the patient was psychotic and delusional, a danger to himself, and that his mental state vacillated back and forth. The medical record lacked evidence the on call psychiatrist was contacted to evaluate Patient #2's mental/psychotic disorder and paranoid/fear of harm to self. Record review revealed the census on the Behavioral Medicine Unit (BMU) on 10/3/17 was 7 patients. The unit had 7 open beds. Review of the local law enforcement's "Call For Service Record", showed documentation which specified that patient # 2 called 911 from the hospital on [DATE] at 9:58 pm and advised that "he did not want to stay there." In a second entry on 10/3/16 at 11:27 pm, "Subject [patient # 2] decided to stay for the time being." On 10/4/16 at 2:15 AM, nursing staff documented in the medical record that Physician P was made aware of the incident. The medical record lacked evidence that ED Physician P re-assessed Patient # 2's emergent medical until 4:51 AM on 10/4/16. Physician P documented in an "Addendum" note that the hospital was attempting to locate placement for the patient since he decided to stay and report will be given to the oncoming physician (ED Physician T) since no placement was located on this shift. Further documentation by ED Physician P indicated the patient was very resistant to receiving any kind of medicines and "flip-flopped" on the issue several times during the time in the ED. On 10/4/16 at 8:52 AM, nursing staff documented the patient was voicing concerns about hearing voices, believed staff from the lab poisoned Patient #2 with a lab draw and certified nursing assistant (CNA) staff were trying to "kill" Patient #2. Review of local law enforcement's "Call For Service Record", showed documentation which specified that patient # 2 called 911 from the hospital a second time on 10/4/16 at 1:57 am. On 10/4/16 at 9:36 AM, nursing staff documented on-call Psychiatrist Q was paged to evaluate the patient because Patient #2 called 911 and said people at the hospital were "here" to hurt Patient #2. On 10/4/16 at 10:25 AM, nursing staff documented St. Anthony Regional Hospital Behavioral Medicine Unit (BMU) Department was contacted for bed placement and was denied because the patient was "not appropriate" for the unit. The medical record did not specify the criteria used to determine the patient was not appropriate for admission to the hospital's psychiatric unit. Review of the hospital's "Admission and Exclusion Criteria to Psychiatric Program" last revised on 4/7/2015 specified in part, "Inpatient hospitalization may be indicated or contraindicated, under the following circumstances:" "1. Inclusion Criteria, a. When the patient demonstrates that, as the result of a mental disorder, he or she presents a danger to himself/herself or other." "b. When documentated outpatient treatment has failed due to the severity of the patient's symptoms, or is unavailable." ... "d. When the patient's orientation, perception, memory, intellect, or judgments are severely impaired due to a mental disorder." Review of the clinical records revealed the census on the BMU on 10/4/17 was 7 patients. The unit had 7 open beds. The medical record did not contain evidence that on-call Psychiatrist Q responded to the page or came to the ED to provide further examination or treatment to stabilize Patient #2's emergency medical condition or that the hospital lacked the necessary capabilities to stabilize the patient's psychiatric emergency. On 10/4/16 at 10:40 AM, nursing staff documented on-call Psychiatrist Q was consulted to evaluate the patient due to difficulty finding placement. The medical record lacked evidence that on-call Psychiatrist Q responded to the request for consult or came to the ED to provide further examination or treatment to stabilize the patient's emergency medical condition. According to the medical record review between 11:30 AM to 3:38 PM on 10/4/16 the patient demonstrated alternating states of anxiety, absence of agitation, irritability, and paranoia. Review of vital signs dated 10/3/16 to 10/4/16 revealed Patient #2's blood pressure varied from 174/118 to 142/98 over the course of the ED . On 10/4/16, ED Physician T documentated an addendum entry at 2:36 PM which included in part, "Assumed care at 0600 (6:00 AM on October 4. Patient definitely demonstrating some psychotic behavior with pronounced paranoia and does appear to present a danger to self and others and therefore a 48 hour hold was obtained and arrangements made for transfer to an appropriate facility...patient will go with the sheriff...patient does have hypertension and therefore was given Toprol XL 100 milligrams (mg) here in the emergency department prior to transfer." Documentation in the medical record showed that ED nursing staff contacted 10 Psychiatric Hospitals for bed placement from the time the patient (MDS) dated [DATE] until 10/4/16 (19 hours) when the patient transferred at 3:58 PM to a 12 bed psychiatric hospital approximately 1.5 hours from Patient #2's home. Arranging for the transfer and the time taken for the transport inappropriately delayed stabilizing treatment for patient # 2's emergency medical condition. During an interview on 10/27/16 at 1:45 PM, ED Physician P stated because the patient wouldn't accept anything to calm down there was very "little" he could do from a psychiatric perspective beside "talk" the patient "down". Physician P said the patient voiced an interest in being evaluated by a psychiatrist and the hospital began making inquiries for a psychiatric bed for Patient #2. When asked what symptoms the patient experienced while he was providing emergent medical care, Physician P said the patient was hypervigilant (an enhanced state of sensory sensitivity accompanied by an exaggerated intensity of behaviors whose purpose is to detect threats, also accompanied by a state of increased anxiety) and paranoid. When asked if he was aware what the census was on the hospital BMU and if there was a bed available for Patient #2, Physician P stated emphatically, "They got some hard and fast rules on that unit about if a patient is violent or has a history of violence they won't take them." Patient #2 needed help and I did the best I could for the patient. During an interview on 11/1/16 at 12:25 PM, the Medical Director of BMU (Psychiatrist Q) said since the hospital did not have a security detail they would not admit patients that have been violent in the past 5 years or are violent when they are in the ED or had a history of assaultive behaviors to their families or to their ED staff. When asked if this was a hospital policy for the 5 year history of violent behavior that would exclude patient's from being admitted to the psychiatric unit, Psychiatrist Q stated he was not aware of a policy but it was hospital protocol and staff checked the "Court on Line" web site to determine if a patient had a history of violence "routinely". When asked if he recalled being paged to the ED to evaluate Patient #2 on 10/4/16, Psychiatrist Q replied, "They may have called me to come see the patient but I was working on the unit and when I got back to them they didn't need me because the patient was being transferred to another hospital." During an observation on 11/1/16 at 1:05 PM, Staff A, Nursing Director of BMU demonstrated how staff access the Iowa Court on Line. At the time of the observation the surveyor requested Staff A to complete a check for Patient #2. During an interview at 3:05 PM, Staff A said she did not find any evidence of a violent record for Patient #2. Review of Credential files revealed Psychiatrist Q was privileged to provide psychiatric services to patients on 2/16 by the Medical Staff and Governing Board.

Based on review of policies, medical records, documents, and interviews with staff, the Critical Access Hospital (CAH), a Medicare participating hospital with specialized psychiatric capabilities and capacity failed to enforce its Emergency Medical Treatment and Labor Act (EMTALA) policies and accept an appropriate transfer of one out of 36 patients with a unstable psychiatric emergency medical condition. (Patient #17) Failure to ensure staff followed their policies and accept an appropriate transfers of a patient with an unstable psychiatric emergency medical condition resulted in nearly a 72 hour delay for Patient # 17's psychiatric evaluation and treatment, and placed the patient at risk for harm and/or death. Findings include: A hospital policy titled, "Admission and Exclusion to Psychiatric Program" Revised: 4/7/2015 included in part, "...PURPOSE: To assist professionals at St. Anthony...to provide quality inpatient treatment for patients 19 years of age or older...INCLUSION CRITERIA...patient demonstrates...as the result of a mental disorder, he or she presents a danger to himself/herself or others...patient's orientation, perception, memory, intellect, or judgments are severely impair due to a mental disorder, behavioral or cognitively impaired will be considered appropriate ...The provider on-call with the Nurse Manager or designee may reserve the right to determine that we are no longer able to accept patients due to acuity or the mix of patients..." 2. A hospital document titled, "BMU (Behavioral Medicine Unit) Referral" Date: 6/25/16, Time: 5:35 AM, ER (emergency room ) stated in part, "...[Patient #17]...suicidal ideation...plan: cut wrists...Voluntary (No court order.)...Fax Received...Advanced Practice Registered Nurse - Psychiatric Mental Health [APRN-PMH A] ... Patient accepted only if a 48 hour hold or a committal based on her history of leaving and coming back the same day and refused placement... [ED RN K] at transferring hospital stated a 48 hour hold or a court committal is not appropriate. The patient is willing to be transferred and admitted . [APRN A] stated will only accept the patient transfer if the patient had a 48 hour hold or a court committal..." A hospital document titled, "St. Anthony Regional Hospital Variance Report" Dated 6/27/16, completed by the Inpatient Psychiatric Manager included in part, "...Date of incident 6/25/16...Additional information...Had a referral from [transferring hospital], for a patient in the emergency room . There were several calls back and forth to get all the information & labs. The patient left the emergency room against medical advice & then returned later, saying she was suicidal again. RN reported to me on Monday 6/27/16 that APRN A told them that we wouldn't consider admission unless they got a court committal. I informed RN that this is a violation of EMTALA, we cannot require a court committal ...What immediate action was taken:...Manager was not aware until Monday morning...How could this have been prevented:...Education of staff on EMTALA laws and violations...What further corrective action is required to prevent reoccurrence:...Will discuss with Nurse Practitioner and educate staff..." A hospital document titled, "Medical Staff Bylaws" Dated 2016, included in part, "...The prerogatives which may be extended to an AHP (Allied Health Professional) shall be defined in the Medical Staff Rules and Regulations or Hospital policies. Such prerogatives may include: b) For Psychiatric Mental Health Advanced Practice Registered Nurse, psychiatric patients may be admitted , discharged , and managed by the psychiatric nurse practitioner, but the sponsoring physician will be the psychiatrist of record for the admission.. All transfers into the hospital are made through Quality Management. They will receive initial contacts, documentation and assess for appropriateness for our hospital. After consultation with the patient's attending physician arrangements for transfer will be made. Physician to physician report is completed prior to the transfer of the patient to this facility..." 3. Review of Patient #17's ED (Emergency Department) medical record faxed from the transferring hospital to St. Anthony's on 6/24/16 at 6:48 PM revealed the following documentation: a. On 6/24/16 at 1:51 PM, ED RN L, documented Patient #17 arrived in ED. On 6/24/16 at 2:28 PM, ED RN L, documented Patient #17 was thinking about hurting/harming self and attempted suicide in the past. b. On 6/24/16 at 4:12 PM, ED RN T documented the following: Presenting Problem: Suicidal Ideation. Patient reports she still feels suicidal and would like to be readmitted . Patient reports she would cut her wrists if she is discharged from the ED. History of Psychiatric Treatment: Patient was discharged earlier this morning from inpatient at the patient's insistence to go to court. Patient presented back to the ED and stated she is still suicidal and would cut her wrists. Suicidal Ideation: Patient reports she would cut her wrists today if she is not readmitted to mental health. Previous Self Harm Plans: Patient reported prior overdose attempt. Previous Suicidal Plans: Cut wrists and overdose. c. On 6/24/16 at 5:19 PM, ED RN T documented the following: Additional Assessment: Doctor Consulted: Psychiatrist U consulted and recommended inpatient mental health admit. Recommendation: Inpatient hospitalization Patient/Family Response: Patient informed that no beds are available at transferring hospital, will attempt to locate a bed for her somewhere in the state. 4. Review of Patient #17's ED medical record the surveyor received from the transferring hospital on [DATE] revealed the following documentation: a. On 6/24/16 at 8:16 PM, ED RN V documented the following: Suicide Risk: Have you attempted suicide in the past: Yes Are you currently thinking about hurting/harming self: Yes SAD (Suicide Assessment) Score: 5 (A score of 3 to 6 consider for hospitalization or very close follow-up.) b. On 6/25/16 at 9:00 AM, Behavioral Health RN W documented the following: Behavioral Health Assessment: Safety - Precautions Type: Suicide Psych Precautions: Suicide Risk Risk Factors - Suicidal Ideation: Patient reports she is still having suicidal thoughts. Affect: Flat c. ED Physician N documentation included the following: On 6/24/16 at 8:38 PM, the patient stated she continued to feel suicidal. Bed placement is still pending at this time. On 6/24/16 at 9:38 PM, St. Anthony's is requesting that the patient be court committed. The patient is agreeable to go to St. Anthony's. At this time there is no legal reason to court commit somebody who is cooperative and could put us in a position where we get in trouble for court committing a cooperative patient. St. Anthony's stated that they will refuse the patient based upon the lack of a court order. 5. During a telephone interview on 6/27/16 at 5:00 PM, ED Physician N from the transferring hospital, reported Patient #17 (MDS) dated [DATE] with a complaint of suicidal ideation, a plan to slit her wrists, depression, a history of bipolar, and borderline personality disorder. ED Physician N reported on-call Psychiatrist U determined Patient #17 required an admission for mental health treatment. ED Physician N reported, there were no psychiatric beds available at the transferring hospital. ED Physician N reported, the patient was cooperative and willing to be admitted at St Anthony's Regional Hospital. ED Physician N stated, if a patient is cooperative and willing to be admitted a court order or 48 hour hold is not needed. ED Physician N indicated that Patient # 17 remained in the transferring hospital's ED for nearly 72 hours before an inpatient psychiatric bed was finally located. During an interview on 6/28/16 at 1:50 PM, the St. Anthony's Behavioral Medicine Unit (BMU) Nurse Manager reported, providers from transferring hospitals call the BMU directly for bed placement. All patients must be medically cleared before coming to the BMU. A BMU nurse will take the call and complete a BMU referral sheet, and use the Admit Criteria Policy to help with acceptance or rejection of the referral. During an interview on 6/29/16 at approximately 10:30 AM, the St. Anthony's ED Director reported, the ED providers do not get involved with accepting transfers of mental health patients from other hospitals. When a hospital calls to request a psychiatric bed placement the call is transferred to the BMU. The ED Director stated, when we have mental health patients in our ED we follow the same procedure. During an interview on 6/29/16 at 12:00 PM, the St. Anthony Inpatient Psychiatric Manager stated, "I told APRN A, a 48 hour hold or court committal is not required for admitting a patient to the BMU. The Inpatient Psychiatric Manager reported, the BMU RN receives the initial telephone call and begins the referral documentation. The BMU RN would ask the transferring hospital about the patient's medical diagnosis and if the patient is a court commitment, a 48 hour hold, a county hold, or a voluntary admission. The Inpatient Psych Manager stated, the BMU RN would ask the transferring hospital to fax a medication list, metabolic profile, alcohol level, TSH (thyroid studies), acetaminophen (Tylenol), and salicylate (aspirin) levels. The BMU RN and the provider discuss the patient, related to the information provided regarding the diagnosis, and waits for the information to be faxed. The Inpatient Psychiatric Manager stated, "After an undetermined amount of time, the BMU RN contacts the transferring hospital and at that time the RN may find out a bed was found at different facility." During an interview on 6/30/16 at 9:45 AM, Advance Practice Registered Nurse (APRN) A stated, I remember the patient [Patient #17], she needed to be on a 48 hour hold for acceptance to be admitted to the BMU. APRN A stated, Patient #17 was at risk for changing her mind about staying in the BMU and may leave. APRN A stated, suicidal ideation is enough reason to get a 48 hour hold. APRN A stated, "My decision to accept or decline the patient was based on the 48 hour hold. This has never been a problem in the past. It is common to have a 48 hour hold or a committal and it wasn't an issue to get one in Kentucky." APRN A stated, "No 48 hour hold was placed on this patient because she was willing to come and I disagreed." APRN A reported, [Patient #17] could not be trusted to stay in the BMU after she left and came back to the transferring hospital ' s ED. Leaving the transferring hospital ' s ED and coming back later showed the patient was unstable. APRN A reported she trained with the BMU Medical Director for approximately 1 week doing rounding and reviewing old referral sheets to understand the procedure for accepting and declining patients for admission to the BMU. APRN A reported she did not receive EMTALA training. During a telephone interview on 6/30/16 at 11:10 AM, BMU RN F stated, I took the initial call from the transferring hospital for Patient #17 on 6/24/16. I requested some background information, lab work, and I was told a 48 hour hold would be obtained for the patient so I informed APRN A. BMU RN F stated, I returned to work in the evening on 6/25/16 and continued to work on placement for the patient. BMU RN F stated, I called the transferring hospital on [DATE] and told a different RN that I received all the materials except the 48 hour hold and the transferring hospital reported the patient was willing to be admitted . BMU RN F stated, I contacted APRN A and she did not understand why there was no 48 hour hold because the patient was suicidal and that is enough for a 48 hour hold order from a judge. During an interview on 6/30/16 at 9:00 AM, the St. Anthony's Inpatient Psychiatric Manager reported on 6/25/16 at 5:35 AM, the BMU had 4 patient beds available and 2 of the 4 patient beds were in 1 empty room. During a second interview on 7/1/16 at 11:25 AM, the Inpatient Psychiatric Manager reported on 6/25/16 at 7:00 PM, the BMU had 8 patient beds available beds and 2 of the 4 patient beds were in 1 empty room. The Inpatient Psychiatric Manager stated, "We had enough nursing staff, and the BMU acuity was such we could have accepted Patient #17 for admission. We had the capacity and the capability to accept Patient #17". A hospital document titled, "BMU - ASSIGNMENTS JUNE 2016" showed on 6/25/16 through 6/27/16, APRN A, was the on-call provider for the BMU at St. Anthony's Regional Hospital. During an interview on 7/5/16 at 11:45 AM, the BMU Medical Director stated, APRN A received 1-2 days of orientation at St. Anthony's Regional Hospital before she started seeing patients at the BMU. The BMU Medical Director stated, APRN A or any provider can call me at any time, some APRNs call more than others. They do not have to call prior to admitting a patient in the BMU. The BMU Medical Director stated, APRN A did not call me prior to when she declined Patient #17's transfer. The BMU Medical Director stated, "We do not require a 48 hour hold for any patient prior to admitting the patient in the BMU. Patient #17 did have a history of leaving and coming back, I would have asked if we needed a 48 hour hold, if not, I would not have required one. If a 48 hour hold is needed after the patient arrives it can be obtained." During an interview on 7/5/16 at 1:45 PM, the Director of Quality Management acknowledged the hospital lacked documentation of Quality involvement in regards to tracking the BMU acceptance of patient transfers for possible violations of the Emergency Medical Treatment and Labor Act (EMTALA) violations.