Based on interviews, review of the facility's Labor and Delivery Logbook, medical record review, and review of facility policies, it was determined the facility failed to ensure stabilizing medical treatment was provided for two (2) of twenty (20) sampled patients (Patient #1 and Patient #3) that presented to the facility's Labor and Delivery Department for an Emergency Medical Condition. Interviews revealed Patient #1 and Patient #3 presented to Labor and Delivery on 06/14/17 with complaints of questionable labor. Patient #1 presented at thirty (30) weeks gestation, gravida 6, para 4 (six pregnancies with four live births) with possible rupture of membranes (clear fluid leaking from vaginal area). Patient #1 was provided a medical screening exam by Registered Nurse (RN) #1 and informed she had ruptured membranes and was dilated one (1) centimeter (cm). RN #1 contacted the Obstetrician (OB) on call (Physician #1) and informed him of Patient #1's condition. Physician #1 directed RN #1 to discharge Patient #1 to go to Facility #2 (78 miles away) in a private vehicle because Facility #2 is where Patient #1 was followed on an outpatient basis. Patient #1 was discharged at 11:42 PM on 06/14/17. Patient #1 went by private vehicle to Facility #2 and was admitted on [DATE] at 1:15 AM with diagnoses of 30.6 weeks gestation, Preterm Premature Rupture of Membranes, Preterm Labor, and Chronic Drug Abuse. Facility #2 made arrangements to transfer Patient #1 to Facility #3 due to Facility #2 only having a Level I Nursery. Facility #2 transferred Patient #1 on 06/15/17 at 3:16 AM via ambulance to Facility #3. Facility #3 admitted Patient #1 on 06/15/17 with a diagnosis of Preterm Premature Rupture of Membranes. Patient #1 delivered a viable male baby on 06/24/17 via Cesarean Section. Facility #3 was still treating Patient #1 and Baby Boy #1 as of the date of this investigation. Patient #3 presented to Facility #1 on 06/14/17 at thirty-five (35) weeks gestation, gravida 3, para 2 (three pregnancies with two live births). Patient #3 received a medical screening exam from RN #1 and was informed that she was dilated two to three (2 to 3) cm with effacement of sixty (60) percent. RN #1 contacted Physician #1 and was given orders to discharge Patient #3 to Facility #2 (78 miles away) in a private vehicle where the patient had been followed on an outpatient basis. Facility #2 admitted Patient #3 on 06/15/17 with diagnoses of Intrauterine Pregnancy at 38 weeks with labor, Subutex (a drug used in the treatment of opioid dependence) Dependent, and Positive Urine Drug Screen for Methamphetamines. Patient #3 delivered a viable female baby on 06/15/17 at 11:43 AM. Facility #2 discharged Patient #3 on 06/17/17. Refer to 42 CFR 489.24 (d)(1-3) Stabilizing Treatment (A2407).

Based on interviews, review of the facility's Labor and Delivery Logbook, medical record review, and review of facility policies, it was determined the facility failed to ensure stabilizing medical treatment was provided for two (2) of twenty (20) sampled patients (Patient #1 and Patient #3) that presented to the facility's Labor and Delivery Department for an Emergency Medical Condition. Interviews revealed Patient #1 and Patient #3 presented to Labor and Delivery on 06/14/17 with complaints of questionable labor. Patient #1 presented at thirty (30) weeks gestation, gravida 6, para 4 (six pregnancies with four live births) with possible rupture of membranes (clear fluid leaking from vaginal area). Patient #1 was provided a medical screening exam by Registered Nurse (RN) #1 and informed she had ruptured membranes and was dilated one (1) centimeter (cm). RN #1 contacted the Obstetrician (OB) on call (Physician #1) and informed him of Patient #1's condition. Physician #1 directed RN #1 to discharge Patient #1 to go to Facility #2 (78 miles away) in a private vehicle because Facility #2 is where Patient #1 was followed on an outpatient basis. Patient #1 was discharged at 11:42 PM on 06/14/17. Patient #1 went by private vehicle to Facility #2 and was admitted on [DATE] at 1:15 AM with diagnoses of [DIAGNOSES REDACTED]#1 to Facility #3 due to Facility #2 only having a Level I Nursery. Facility #2 transferred Patient #1 on 06/15/17 at 3:16 AM via ambulance to Facility #3. Facility #3 admitted Patient #1 on 06/15/17 with a diagnosis of [DIAGNOSES REDACTED]#3 was still treating Patient #1 and Baby Boy #1 as of the date of this investigation. Patient #3 presented to Facility #1 on 06/14/17 at thirty-five (35) weeks gestation, gravida 3, para 2 (three pregnancies with 2 live births). Patient #3 received a medical screening exam from RN #1 and was informed that she was dilated two to three (2 to 3) cm with effacement of sixty (60) percent. RN #1 contacted Physician #1 and was given orders to discharge Patient #3 to Facility #2 (78 miles away) in a private vehicle where the patient had been followed on an outpatient basis. Facility #2 admitted Patient #3 on 06/15/17 with diagnoses of [DIAGNOSES REDACTED]. Facility #2 discharged Patient #3 on 06/17/17. The findings include: Review of the facility's policy titled "EMTALA-Stabilization," reviewed 10/14/08, revealed the facility was to provide such medical treatment as was necessary to assure, within reasonable medical probability, that no material deterioration of the condition was likely to result from, or occur during, the transfer of the individual from the facility; or, with respect to a pregnant woman who was having contractions and who cannot be transferred before delivery without a threat to the health and safety of the woman or unborn child, that the woman has delivered the child and the placenta. Review of the facility's policy titled "EMTALA-Transfer," reviewed 10/14/08, revealed the facility provided further medical examination and treatment, including hospitalization , if necessary, as required to stabilize the medical condition within the capabilities of the staff and facilities available at the hospital; or to transfer to another more appropriate or specialized facility after provision of treatment necessary to minimize the risks to the health of the individual or, in the case of a pregnant female, to the unborn child. Further review of the policy revealed any legally responsible person acting on the patient's behalf must first be fully informed of the risks of a transfer, the alternatives to transfer, and of the facility's obligations to provide further examination and treatment sufficient to stabilize the patient's Emergency Medical Condition or by a physician's order with the appropriate physician certification. The policy stated that to provide an appropriate transfer the following was required: the transferring facility must within its capability provide treatment to minimize the risks to the health of the individual or unborn child; the receiving facility must have available space and qualified personnel for the treatment of the individual and must have agreed to accept the transfer and provide appropriate treatment; and the transferring facility must send copies of all available medical records pertaining to the individual's emergency condition to the facility where the patient is being transferred. Review of the credentialing file for Physician #1 on 06/26/17 at 2:00 PM revealed Physician #1 was appointed privileges on 11/02/76 and reappointed on 11/01/16; however, there was no documented evidence the facility oriented/educated Physician #1 on their EMTALA policies. Review of the Labor and Delivery Logbook revealed Patient #1 (MDS) dated [DATE] at 11:00 PM with a chief complaint of questionable rupture of membranes (her water broke). Continued review of the logbook revealed Patient #1 was discharged on [DATE] at 11:55 PM with a disposition of "home to go to [Facility #2]." Further review of the Labor and Delivery logbook revealed Patient #3 (MDS) dated [DATE] at 10:55 PM with a chief complaint of questionable labor. Patient #3 was discharged at 12:00 AM on 06/15/17 with a disposition of "home to go to [Facility #2]." 1. Review of Patient #1's medical record revealed the facility received Patient #1 on 06/14/17 with a diagnosis of [DIAGNOSES REDACTED]. RN #1 documented Patient #1 had ruptured membranes (clear fluid seen leaking from vagina), with no bleeding, dilation of one (1) centimeter (cm), effacement" thick," and station -2. Continued review of the record revealed RN #1 had documented at 11:30 PM a phone call to Physician #1. RN #1 documented that she informed Physician #1 that Patient #1 had been on the monitor for fifteen (15) minutes and that the patient was at 30.5 weeks gestation, gravida 6, para 4. RN #1 stated that she had performed a medical screening exam and that the patient had a clear fluid observed trickling from her vagina with a nitrozine level of 7.5. Further review of Patient #1's medical record revealed RN #1 documented that Physician #1 stated, "I think the best thing to do is discharge [Patient #1] and tell her to go on to [Facility #2] where she had planned to deliver to her regular doctor." RN #1 then documented that she asked Physician #1, "Do you want to transfer her to [Facility #2]?" Physician #1 stated, "No, [Patient #1] is not having contractions and she is only dilated to one (1) centimeter. It will be faster to discharge her and instruct her to go on her own." Again RN #1 stated, "[Patient #1's] water is broke, do you want to transfer her? We can try to get an ambulance if you call and get an accepting doctor." RN #1 documented that Physician #1 stated, "No, tell her to go on over there now, we don't have a NICU [neonatal intensive care unit] here and we can't keep a 30-week baby; it will be better to just go on down there where her regular doctor is." RN #1 then documented that she stated to Physician #1, "I want to clarify with you that you know [Patient #1] is at 30 weeks and her water is broke and that you told me to discharge her and instruct her to go to [Facility #2]?" Physician #1 stated, "Yes, she is not contracting, discharge her now and tell her to go to her regular doctor and hospital." Facility #1 discharged Patient #1 at 11:55 PM. Interview with RN #1 on 06/26/17 at 3:30 PM revealed that she was working in Labor and Delivery on 06/14/17 and conducted the medical screening exam on Patient #1. RN #1 stated she checked Patient #1 when she first arrived and the patient was dilated to one (1) centimeter at that time. RN #1 stated that Patient #1 came in with a "towel between her legs and clear fluid leaking from her vagina." RN #1 stated that Patient #1 had ruptured membranes and she was very concerned because Patient #1 was only at 30 weeks gestation. RN #1 stated, "We always transfer patients like her, we never discharge them." RN #1 stated that when she contacted Physician #1, she expected to receive a transfer order and when she did not, she stated she questioned Physician #1 for "several minutes." RN #1 stated once she hung up with Physician #1, she contacted the House Supervisor because she did not agree with Physician #1's order for Patient #1. RN #1 stated the House Supervisor instructed her to contact the OB Manager. Continued interview with RN #1 revealed that the OB Manager instructed her to follow Physician #1's orders. RN #1 stated she then discharged Patient #1 from the facility. Interview with the OB Manager on 06/26/17 at 12:00 PM revealed that she was contacted by RN #1 on 06/14/17 regarding Patient #1. The OB Manager stated that she did instruct RN #1 to follow Physician #1's orders. Continued interview with the OB Manager revealed that she stated she thought about the situation for a few minutes and then contacted the House Supervisor so she could contact the Administrator on Call for direction. The OB Manager stated she then contacted RN #1 but by that time, Patient #1 had been discharged from the facility. The OB Manager stated that a patient with those circumstances should never be discharged , they should be monitored and transferred. Interview with Physician #1 on 06/26/17 at 1:21 PM revealed he was the on-call OB on 06/14/17 for Facility #1. Physician #1 stated that he did speak with RN #1 regarding Patient #1. Physician #1 stated that Facility #1 did not have the capability to care for a 30-week newborn and that he was "saving" time when he gave the order to discharge rather than to transfer. Physician #1 stated that sometimes it takes hours to have an ambulance respond to a request to transport a patient to another facility and he did not want to take the chance of the baby being delivered at Facility #1. Further interview with Physician #1 revealed that he thought Facility #2 had a Level II NICU nursery to provide care for the newborn baby. Physician #1 stated that because Patient #1 was only dilated to 1 centimeter and not contracting, he felt it was safe to discharge her by private vehicle and go on her own to Facility #2. Interview with Physician #2 on 06/26/17 at 5:00 PM revealed he was the Medical Director for the OB unit at Facility #1. Physician #2 stated that given the set of circumstances surrounding Patient #1, he professionally would not have discharged the patient. He stated that he would have transferred her via ambulance to another facility. Further interview with Physician #2 revealed that had the Administrator on Call contacted him regarding this situation, he would have instructed RN #1 to follow Physician #1's orders because Physician #1 was his partner and it was difficult to go against his medical opinion. Review of Patient #1's medical record from Facility #2 revealed the facility admitted Patient #1 on 06/15/17 at 1:15 AM with diagnoses of [DIAGNOSES REDACTED]#1 to Facility #3 due to Facility #2 only having a Level I Nursery. Facility #2 transferred Patient #1 on 06/15/17 at 3:16 AM via ambulance to Facility #3. Facility #3 admitted Patient #1 on 06/15/17 with a diagnosis of [DIAGNOSES REDACTED]#3 was still treating Patient #1 and Baby Boy #1 as of the date of the investigation. Patient #1's baby boy was diagnosed with [DIAGNOSES REDACTED]'s response to infection causes injury to its own tissues and organs), Feeding problems of a newborn, [DIAGNOSES REDACTED] status post surfactant (a syndrome in premature infants caused by developmental insufficiency of pulmonary surfactant production and structural immaturity in the lungs; it can also be a consequence of neonatal infection), and Hypotension (low blood pressure). 2. Review of the medical record for Patient #3 revealed Facility #1 admitted the patient on 06/14/17 at 10:55 PM with a chief complaint of questionable labor. Patient #3 stated she was at thirty-nine (39) weeks gestation, gravida 3, para 2. Patient #3 received a medical screening exam from RN #1 and informed the patient that she was dilated two to three (2 to 3) centimeters with effacement of sixty (60) percent. RN #1 contacted Physician #1 at 11:30 PM and informed Physician #1 that he was the OB on call for unassigned patients and that Patient #1 was at 39 weeks gestation, gravida 3, para 2 with questionable labor and dilated 2-3 centimeters. RN #1 documented that Physician #1 stated, "Tell her to go to [Facility #2] to her doctor." RN #1 documented that she asked Physician #1 again to clarify that he wanted to discharge Patient #3 and Physician #1 stated, "Yes, discharge her and tell her to go to [Facility #2] where she goes to the doctor." RN #1 documented that she contacted the House Supervisor and the OB Unit Manager and informed them of Physician #1's orders to discharge Patient #3 to Facility #2 and that she was instructed to "do what [Physician #1] told you to do." Patient #3 was discharged at 12:00 AM on 06/15/17 with a disposition of "home to go to [Facility #2]." Review of the medical record for Patient #3 from Facility #2 revealed the facility admitted Patient #3 on 06/15/17 at 3:45 AM with diagnoses of [DIAGNOSES REDACTED]. Facility #2 discharged Patient #3 on 06/17/17. Interview with RN #1 on 06/26/17 at 3:30 PM revealed that she was working in Labor and Delivery on 06/14/17 and conducted the medical screening exam on Patient #3. RN #1 stated that Patient #3 was at 39 weeks gestation and dilated to 2-3 centimeters. RN #1 stated that she informed Physician #1 of Patient #1's symptoms and that he gave her orders to discharge Patient #3 to home to go to Facility #2. RN #1 stated that she contacted the House Supervisor and OB Unit Manager and was told to follow Physician #1's orders so that is what she did. Interview with Physician #1 on 06/26/17 at 1:21 PM revealed he was the on-call OB on 06/14/17 for Facility #1. Physician #1 stated that he did speak with RN #1 regarding Patient #3. Physician #1 stated that he recalled that Patient #3 was a term pregnancy and the baby was in a breech position. Physician #1 stated that from the information that RN #1 told him he was unsure if Patient #3 was in labor and he gave orders to discharge Patient #3 to home and for her to go to Facility #2 where her OB delivered babies and for her to follow up with them. Physician #1 stated that he felt like he gave orders that were in the best interest of the baby. Interview with the Chief Nursing Officer (CNO) and the Risk Manager on 06/26/17 at 3:30 PM revealed that they became aware of the incident on 06/15/17 when they were contacted by Facility #2. The Risk Manager stated that Physician #1 should have transferred Patient #1 and Patient #3 rather than discharging them. The CNO and the Risk Manager stated that on 06/19/17 all OB staff was re-educated on EMTALA policies and on 06/21/17 all Providers were re-educated on EMTALA policies and procedures. Physician #1 and Physician #2 were educated separately on 06/26/17 and Facility #1 held a Medical Staff Meeting on 06/26/17 where the Chief Executive Officer, the CNO, and the Risk Manager spoke regarding EMTALA policies and procedures to the entire medical staff.

Based on interviews, record reviews, and review of facility policies, it was determined the facility (Facility #1) failed to provide a medical screening and appropriately transfer one (1) of twenty (20) patients (Patient #1, an adolescent). On 05/27/17, Patient #1 presented to the Emergency Department (ED) of Facility #1 with his/her mother with cuts to the wrist and suicidal ideation. Registered Nurse (RN) #1 told Patient #1's family during triage that the facility did not treat adolescents with a psychiatric condition and Patient #1's mother requested transfer to Facility #2. During triage, RN #1 assessed that the patient had suicidal ideation, intent, a plan, and access to "lethal means." According to the assessment, Patient #1's suicide risk was "moderate" and the patient was placed on suicide precautions. Advanced Practice Registered Nurse (APRN) #1 assessed Patient #1 and determined the patient had Suicidal Thoughts, Depressive Disorder, and Superficial Self-Inflicted Cut to left wrist; however, there was no evidence a "psychiatric screening" was conducted as required by the facility's policy to determine whether an emergency medical condition existed. The facility attempted to arrange a transfer to Facility #2; however, Facility #2 did not send requested paperwork to Facility #1. In the meantime, APRN #1 discharged Patient #1 with the patient's mother and grandfather to have them transport Patient #1 to Facility #2 (a facility sixty-nine (69) miles away) and did not arrange the transfer of the patient to ensure the patient's safety. Patient #1's family transported the patient to Facility #2 in their private vehicle and Facility #2 admitted Patient #1 on 05/27/17 for treatment of Depressive Disorder and Suicidal Ideation.

Based on interview, record review, and review of facility policies, it was determined the facility (Facility #1) failed to provide an appropriate medical screening for one (1) of twenty (20) patients (Patient #1). Patient #1 presented to the Emergency Department (ED) on 05/27/17, with cuts to the wrist and suicidal ideation. Advanced Practice Registered Nurse (APRN) #1 conducted a medical screening; however, there was no evidence a "psychiatric screening" was conducted as required by the facility's policy, to determine whether an emergency medical condition existed. APRN #1 determined Patient #1 was stable and discharged Patient #1 with the understanding that the patient's mother would transport Patient #1 to Facility #2 for treatment of the patient's psychiatric condition. Patient #1's family transported the patient to Facility #2 in their private vehicle and Facility #2 admitted Patient #2 on 05/27/17 for treatment of Depressive Disorder and Suicidal Ideation. The findings include: Review of the facility's policy titled "EMTALA-Medical Screening," reviewed 10/14/08, revealed the facility defined a medical screening exam and the "process required to reach, with reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition exists." The policy stated that such screening must be completed within the facility's capability and available personnel, to include on-call physicians. The medical screening exam is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred. The policy stated the screening was required to be conducted to the extent necessary "to determine whether an emergency medical condition exists with respect to a psychiatric patient, a medical screening consists of both a medical screening examination and a psychiatric screening." Review of the credentialing file for Physician #1 and APRN #1 revealed no documented evidence the facility oriented/educated the providers on the facility's EMTALA policies and no evidence the providers had psychiatric education/certification. Interview with the ED Director on 06/20/17 at 2:15 PM revealed when a patient presented to the ED with a psychiatric diagnosis, staff from the behavioral health unit were required to conduct a psychiatric screening for the patient; however, behavioral health staff only screened adult patients and the facility did not have a procedure in place to screen adolescent patients as required per the facility's policy. Review of the medical record for Patient #1 revealed Patient #1 arrived at the facility on 05/27/17 at 5:25 PM and Patient #1 was triaged at 6:24 PM for suicidal thoughts. Registered Nurse (RN) #1 documented during the triage assessment that Patient #1 had complained of suicidal ideation for one (1) day. Patient #1 cut himself/herself with a razor on the left wrist and had several superficial lacerations on the left wrist. Patient #1 complained of anxiety and depression. Patient #1 stated he/she was not sure why he/she was suicidal and felt depressed and suicidal "sometimes." RN #1 documented on the Suicide Risk Assessment that "Patient #1 expressed thoughts of harming self/others." According to the assessment, the patient had suicidal ideation, intent, a plan, and access to "lethal means." According to the assessment, Patient #1's suicide risk was "moderate" and the patient was placed on suicide precautions. Continued review of Patient #1's medical record revealed APRN #1 started an exam of Patient #1 on 05/27/17 at 6:53 PM. APRN #1 documented that she reviewed and agreed with RN #1's assessment. The APRN stated the patient presented with symptoms of depression and had "definite suicidal thoughts and has a plan." However, APRN #1 documented under the "psychiatric" portion of the physical exam that Patient #1 had suicidal ideation; however, "on questioning patient does not have a concrete plan regarding suicide and is rather vague." According to the assessment, Patient #1 had a healing scar on the left lower arm and had superficial, self-inflicted cuts. APRN #1 diagnosed Patient #1 with Suicidal Thoughts, Depressive Disorder, and Superficial Self-Inflicted Cut to left wrist. Continued review of the record revealed RN #2 documented on 05/27/17 at 7:02 PM that she contacted Facility #2, spoke with a staff member, and was having forms faxed from Facility #2 to Facility #1. RN #2 documented at 7:19 PM that the forms from Facility #2 had not been received. Further review of Patient #1's medical record revealed APRN #1 documented at 8:48 PM that "Mom to take [Patient #1] to [Facility #2] tonight for suicidal thoughts." Physician #1 also documented at that time (8:48 PM on 05/27/17) that he had examined Patient #1, "conducted a "face-to-face encounter," and agreed with the "mid-level assessment" and plan of care. According to Patient #1's medical record, the facility discharged Patient #1 on 05/27/17 at 9:00 PM with the patient's mother. Review of Patient #1's medical record from Facility #2 revealed the patient presented at Facility #2's ED on 05/27/17 at 11:05 PM with a "Mental Health Disorder" and was diagnosed with Self-Mutilating Behavior and Suicidal Thoughts. Patient #1 was admitted to Facility #2 on 05/28/17 for treatment of Depressive Disorder and Suicidal Ideation. Patient #1 was discharged home on 05/30/17 with outpatient treatment planned. An interview with Patient #1's family was attempted on 06/20/17 at 11:55 AM and 6:21 PM and on 06/21/17 at 10:50 AM without success. Interview with RN #1 on 06/20/17 at 12:00 PM revealed he was the triage nurse on 05/27/17 when Patient #1 was brought into the ED for treatment of suicidal ideation. RN #1 stated he conducted the triage assessment for Patient #1 and found that he/she had several superficial cuts on the left wrist and that Patient #1 stated he/she was having suicidal thoughts. RN #1 stated he placed Patient #1 on suicide precautions (which is 1:1 care and the patient is searched for safety) and had no other contact with Patient #1. RN #1 stated he had specialized behavioral health training and often conducted psychiatric screenings for adults who presented to the ED with a psychiatric illness; however, RN #1 stated he was not trained to conduct a psychiatric screening for adolescents. Interview with APRN #1 on 06/20/17 at 1:25 PM revealed the facility did not have the capability to assess/treat adolescents with psychiatric illness and she did not have any advanced education/certification in behavioral health; however, she stated she assessed Patient #1 on 05/27/17 for complaints of suicidal ideation. APRN #1 stated she discharged the patient because she felt the patient was stable and did not have a suicide plan. APRN #1 stated she discharged Patient #1 with the knowledge that the family was taking the patient to Facility #2. Attempts to interview Physician #1 were unsuccessful; however, a review of Physician #1's statement to the facility dated 06/08/17 at 8:11 AM revealed he examined Patient #1 via "Intra net [electronic medical record]" (Physician #1's documentation stated he conducted a "face-to-face assessment) and agreed with APRN #1 to discharge Patient #1 so the patient's family could transport Patient #1 to Facility #2. The physician stated the steps were taken on the guardian's insistence that they take the patient to Facility #2 because they wanted to save time. Physician #1 stated, " ...we did not need to call them [Facility #2] as it might take few hours to complete the process." Interview with the facility's Risk Manager on 06/20/17 at 10:15 AM revealed the facility recognized Patient #1 was not transferred per policy and the facility began educating staff regarding the facility's policy on EMTALA. Further interview with the Risk Manager and review of the facility's educational material revealed on 06/07/17, the facility re-educated all ED staff and on 06/08/17 all ED providers were educated. The facility also completed individualized education for Physician #1 and APRN #1 regarding the facility's EMTALA policy.

Based on interviews, record reviews, and review of facility policies, it was determined the facility (Facility #1) failed to appropriately transfer one (1) of twenty (20) patients (Patient #1, an adolescent) when Patient #1's family requested transfer to Facility #2. On 05/27/17, Patient #1 presented to the Emergency Department (ED) of Facility #1 with cuts to his/her wrist and suicidal ideation. Staff told Patient #1's family that the facility did not treat adolescents with a psychiatric condition and Patient #1's mother requested transfer to Facility #2. The facility attempted to arrange a transfer to Facility #2; however, Facility #2 did not send requested paperwork to Facility #1. Advanced Practice Registered Nurse (APRN) #1 then discharged Patient #1 to the care of his/her mother and grandfather to have them transport Patient #1 to Facility #2 (a facility sixty-nine (69) miles away) and did not arrange the transfer of the patient to ensure the patient's safety. The findings include: Review of the facility's policy titled "EMTALA-Transfer Policy," reviewed 10/14/08, revealed the facility was required to ensure that a patient that requested or required transfer for further medical care and follow-up in connection with treatment for an Emergency Medical Condition was transferred appropriately. Further review of the policy revealed any legally responsible person acting on the patient's behalf must first be fully informed of the risks of a transfer, the alternatives to transfer, and of the facility's obligations to provide further examination and treatment sufficient to stabilize the patient's Emergency Medical Condition. The policy stated that to provide an appropriate transfer the following was required: the transferring facility must within its capability provide treatment to minimize the risks to the health of the individual; the receiving facility must have available space and qualified personnel for the treatment of the individual and must have agreed to accept the transfer and provide appropriate treatment; and the transferring facility must send copies of all available medical records pertaining to the individual's emergency condition to the facility where the patient was being transferred. Review of the credentialing file for Physician #1 on 06/20/17 at 2:00 PM revealed Physician #1 was appointed privileges on 07/07/15 and reappointed on 02/01/17; however, there was no documented evidence the facility oriented/educated Physician #1 on their EMTALA policies. Review of the credentialing file for APRN #1 on 06/20/17 at 2:00 PM revealed APRN #1 was appointed privileges on 08/21/15 and reappointed on 02/01/17; however, there was no documented evidence the facility oriented/educated APRN #1 on their EMTALA policies. Review of the medical record for Patient #1 revealed Patient #1 arrived at the facility on 05/27/17 at 5:25 PM and Patient #1 was triaged at 6:24 PM for suicidal thoughts. Registered Nurse (RN) #1 documented during the triage assessment that Patient #1 had complained of suicidal ideation for one (1) day. Patient #1 cut himself/herself with a razor on the left wrist and had several superficial lacerations on the left wrist. Patient #1 complained of anxiety and depression and felt depressed and suicidal "sometimes." RN #1 documented on the Suicide Risk Assessment that "Patient #1 expressed thoughts of harming self/others." According to the assessment, the patient had suicidal ideation, intent, a plan, and access to "lethal means." According to the assessment, Patient #1's suicide risk was "moderate" and the patient was placed on suicide precautions. Continued review of the record revealed RN #2 documented on 05/27/17 at 7:02 PM that she contacted Facility #2 to arrange transfer, spoke with a staff member, and was having forms faxed from Facility #2 to Facility #1. RN #2 documented at 7:19 PM that the forms from Facility #2 had not been received. However, a review of APRN #1's documentation revealed she did not arrange a transfer to Facility #2, but discharged Patient #1 on 05/27/17 at 8:48 PM to be transported by private vehicle by his/her mother and grandfather to Facility #2. Physician #1 also documented at 8:48 PM on 05/27/17 that he had seen and examined Patient #1 and agreed with APRN #1's recommendations and findings. Interview with RN #1 on 06/20/17 at 12:00 PM revealed he was the triage nurse on 05/27/17 when Patient #1 was brought to the ED for treatment of suicidal ideation. RN #1 stated Patient #1's mother reported the patient was suicidal and she requested Patient #1 be admitted to the facility. RN #1 stated he informed Patient #1's mother that the facility did not treat adolescent psychiatric illness and the closest facility that treated adolescents was Facility #2. RN #1 stated he then conducted the triage assessment of Patient #1 and found that he/she had several superficial cuts to the left wrist. Patient #1 stated he/she was having suicidal thoughts, but did not tell him if he/she had a plan. RN #1 stated he placed Patient #1 on suicide precautions (which is one-on-one care and the patient is searched for safety). RN #1 stated that was the last contact he had with Patient #1. Review of the "Behavioral Health Evaluations Patient Monitoring Record" dated 05/27/17 revealed Patient #1 was on suicide precautions and received one-to-one monitoring from 7:00 PM to 9:00 PM on 05/27/17 and the monitoring was provided by RN #2 from 7:00 PM until 8:00 PM. Interview with RN #2 on 06/20/17 at 1:50 PM revealed she was Patient #1's nurse and contacted Facility #2 about admission to their psychiatric unit. She stated Facility #2 stated they would fax information to Facility #1 regarding the transfer; however, Facility #1 never received the paperwork. In the meantime, APRN #1 discharged Patient #1. RN #2 stated she was aware Patient #1's family was taking the patient to Facility #2 for treatment and normally when transferring a patient to another facility the patient was not discharged , but a transfer was initiated by the physician and documentation and report to the receiving facility was required. Interview with APRN #1 on 06/20/17 at 1:25 PM revealed she did not have any advanced education/certification in behavioral health; however, she stated she assessed Patient #1 on 05/27/17 for complaints of suicidal ideation. APRN #1 stated she felt the patient was stable and did not have a suicide plan. She further stated the facility did not have the capability to assess/treat adolescents with psychiatric illness and planned to discharge the patient home to follow up with outpatient treatment; however, Patient #1's mother wanted the patient transferred to Facility #2 for treatment. APRN #1 stated she discharged Patient #1 with the knowledge that the family was taking the patient to Facility #2. APRN #1 stated she did not arrange a transfer for Patient #1 as requested by the patient's family. An interview with Patient #1's family was attempted on 06/20/17 at 11:55 AM and 6:21 PM and on 06/21/17 at 10:50 AM without success. Review of Patient #1's medical record from Facility #2 revealed the patient presented at Facility #2's ED on 05/27/17 at 11:05 PM with a "Mental Health Disorder" and was diagnosed with Self-Mutilating Behavior and Suicidal Thoughts. Patient #1 was admitted to Facility #2 on 05/28/17 for treatment of Depressive Disorder and Suicidal Ideation. Patient #1 was discharged home on 05/30/17 with outpatient treatment planned. Interview with the facility's Risk Manager on 06/20/17 at 10:15 AM revealed the facility recognized Patient #1 was not transferred per the facility's policy and the facility began educating staff regarding the facility's policy on EMTALA. Further interview with the Risk Manager and review of the facility's educational material revealed on 06/07/17 the facility re-educated all ED staff, and on 06/08/17 all ED providers were educated. The facility also completed individualized education for Physician #1 and APRN #1 regarding the facility's EMTALA policy on 06/08/17.