Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires that hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases The hospital failed to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. This deficient practice is evidenced by failing to provide continuous monitoring to a patient presenting with suicidal ideations until a medical screening was completed to determine if the patient had an emergency medical condition for 1 (#2) of 20 patients reviewed that presented to the pediatric emergency room (see findings Fed-A-2406).

Based on record review, video review and interviews, the hospital failed to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. This deficient practice is evidenced by failing to provide continuous monitoring to a patient presenting with suicidal ideations until a medical screening was completed to determine if the patient had an emergency medical condition for 1 (#2) of 20 patients reviewed that presented to the pediatric emergency room . Findings: Review of the hospital's policy titled Observation and Monitoring of Behavioral Patients in the Emergency Care Setting revealed in part: 2. Behavioral patients in the ECU under suicide precautions will have Level 2 observation status unless deemed otherwise by a physician. 3. Observation and monitoring of behavioral patients is delegated from Registered Nurse to appropriate unlicensed staff and the RN attains accountability and supervision. The observation of patients in the Emergency Care setting requiring 1:1 observation or Visual Observation will be performed by a Registered Nurse, Mental Health Tech, Security, or other staff member trained in the observation of this patient population. Review of Patient #2's emergency department record revealed she was a [AGE] year old that arrived to the pediatric emergency department with her mother on 3/15/19 at 8:14 p.m. with the chief complaint of having suicidal thoughts. The next documentation was that Patient #2 was triaged in LA-Triage 01 at 9:09 p.m. (55 minutes later). Further review revealed a Suicide Risk assessment was done at 9:11 p.m. by the triage nurse and Patient #2 was scored as a high risk. Patient #2 was then place in room B10 (safe for psychiatric patients) with staff observing her for safety. Patient #2 was seen by a Physician's Assistant on 3/15/19 at 10:45 p.m. Review of emergency department room availabilty for 3/15/19 revealed a psychiatric safe room (B10) became available at 8:20 p.m. which was 6 minutes after Patient #2's arrival to the registration desk. Further review revealed the room was available until Patient #2 was placed into it at 9:14 p.m. Review of a Physician's Emergency Certificate dated 3/16/19 at 1:04 a.m. revealed Patient #2 was determined to be suicidal, a danger to herself and unable to seek voluntary admission. In a telephone interview on 3/22/19 at 8:00 a.m. with Patient #2's mother, she said they registered her daughter as having suicidal thoughts and then they were placed into the waiting room for a long time before being seen. She said they did not have a staff member with them. She said she kept asking to see a doctor and they kept telling her the doctor was busy. In an interview on 3/22/19 at 9:45 a.m. with S3EDDir, she said if a patient presents to the ED with suicidal ideations or attempt, they will be taken to the back immediately and never wait in the waiting room. She said personnel was automatically assigned to the patient even if they have a family member with them. In an interview on 3/22/19 at 2:30 p.m. with S4MD, he said if a patient presents as suicidal to the ED they were labeled as a level 2. He said the patient had to see a provider faster if they were a level 2. S4MD said he thought the patient had to be seen in less than 10 minutes but he was not sure. He also said suicidal patients should never go to the waiting room. S4MD said all level 2 patients are taken directly to the back. In an interview on 3/22/19 at 3:09 p.m. with S5MD, she said she was working in the ED on 3/15/19 and 3/16/19. She said when a patient arrived with suicidal ideations they are taken into triage immediately. She said she had never seen a case where the patient was sent to the waiting room. In an interview on 3/26/19 at 9:05 a.m. with S1Compliance, she said she reviewed a video of the Pediatric Emergency Department waiting room for the time frame Patient #2 was being admitted on [DATE]. She said it appears to be Patient #2 and her mother in the video and the time frames correlate with the documentation in Patient #2's medical record. S1Compliance said after Patient #2 was registered, she and her mother did return to the waiting room unsupervised for approximately 40 minutes. S1Compliance said that is not the hospital's usual practice. She said when someone presents as suicidal they are supposed to be either taken into triage or placed in a safe room immediately. S1Compliance said she is not sure why Patient #2 and her mother were allowed to sit in the lobby.

Based on record review and interviews, the hospital failed to provide documented evidence to indicate an appropriate transfer was provided for 1 (#2) of 20 patients who presented to the hospital's ED with an emergency medical condition. This failed practice was evidenced by Patient #2 being transferred to another facility when the transferring hospital had the capability and capacity to provide services. Findings: Review of the Hospital Policies titled Patient Transfer revealed in part: 2. If medical treatment has been provided within available capabilities and it is determined to be in the best interest of the patient to transfer to another facility, the following process will be followed. a. Patient condition will be stabilized to the point that within reasonable medical probability, no material deterioration will occur during or as the result of transfer. b. The patient or person acting on the patient's behalf will be informed by the physician of the hospital's obligations under the OBRA/COBRA regulations, medical benefits associated with the transfer and risks if the transfer does not occur. Review of Patient #2's medical record revealed she had been accepted as an ED to ED transfer from Hospital "A"s emergency department on 11/17/16 at 8:51 p.m. because Hospital "A" did not have neurosurgery services available. Further review revealed Patient #2 was then transferred to Hospital "B" on 11/18/16 at 2:25 a.m. Review of Patient #2's medical record revealed a MRI radiology report from Hospital "A" dated 11/17/16 at 3:59 p.m. revealed the following: Clinical Indication: Back pain, bladder incontinence and lower extremity numbness status post recent fall. Findings: There is an acute appearing anterior compression fracture of the T12 vertebral body with approximately 50% loss of vertebral body height and adjacent bone marrow edema. There is T12 vertebral body fracture retropulsion causing moderate central canal stenosis just below the T11-12 level contacting and mildly deforming the adjacent distal cord without evidence of cord edema. Review of a progress note by S2PA (the on call neurologist's PA) dated 11/17/16 at 10:00 p.m. revealed the following: [AGE] year old female status post fall on 11/1/16. Complains of immediate back pain and bladder incontinence started several days after. PCP sent her to the ER at Hospital "A" where lumber MRI was done showing T12 compression fracture with moderate canal stenosis. Decreased sensation left 2nd/3rd toes , foley catheter AIP: T12 compression fx 1) NSG recommendation is transfer pt to Hospital "B" for treatment. 2) pt refuses transfer due to family issues in Baton Rouge. 3) will order non custom TLSO brace. 4) Explained to pt that urinary incontinence can become permanent if she does not go to Hospital "B". Review of Patient #2's Transfer Record revealed the reason for transfer was to a higher level of care. Further review revealed the follwing statements: You are being transferred to another facility that has a particular service that you need for continued stabilization of your condition. We are currently unable to offer those services at this facility. The specialty service that you require is ortho-spinal. Review of Patient #2's nurses notes dated 11/17/16 revealed an entry by S3RN at 10:45 p.m.: Notified charge nurse S4RN of suspected EMTALA violation. Pt states, "They are transferring me because of my Medicaid, they told me so". 10:45: Was told by charge nurse S4RN, "We do this all of the time, don't worry about it". 10:45: Called neuro to verify this, spoke with PA who confirmed that she told the patient, "We are sending you to Hospital "B" because of your Medicaid. In a phone interview on 4/11/17 at 10:30 a.m. with Patient #2, she said she was embarrassed when S2PA told her they would not operate on her at Our Lady of the Lake Regional Medical Center because she was a Medicaid patient. Patient #2 said after she refused the transfer to Hospital "B", S3PA told her if she did not go to Hospital "B" she could be paralyzed so she changed her mind. Patient #2 said after she arrived at Hospital "B", she was admitted to the ICU and had spine surgery within 4 hours. In an interview on 4/12/17 at 7:35 a.m. with S5MD, he said he was an ED physician at the hospital and he was working the night Patient #2 had been transferred from Hospital "A". He said Hospital "A" did not have neurosurgery capacity. S5MD said they accepted Patient #2 because they had neurosurgery on call. He said S2PA came to the ED for neurosurgery on call and assessed Patient #2. He said S2PA indicated the patient needed further care and said it would be easier for her to go to Hospital "B". S5MD verified S6Neuro was capable of doing the type of surgery Patient #2 required. In an interview on 4/12/17 at 7:55 a.m. with S6Neuro, he said he was the neurosurgeon on call for the hospital on [DATE]. He said Patient #2 was transferred from Hospital "A" because she had a compression fracture and they did not have neuro coverage. S6Neuro said Patient #2 needed surgery for her injury. S6Neuro said he has a relationship with Hospital "B" and the environment was good for large cases. He said Patient #2's surgery would require a group of people to coordinate. He said it is good for the residents in training at Hospital "B". He said coordinating with other services at Our Lady of the Lake Regional Medical Center was complex because they had to coordinate the vascular service and the equipment company in the middle of the night and schedule the OR time. S6Neuro also verified he had the capability to do the surgery here at the hospital and had done the type of surgery she needed in the past. In an interview on 4/12/17 at 8:36 a.m. with S2PA, she said she worked for a neurosurgical group. S2PA said she was taking call with S6Neuro on 11/17/16. She said Patient #2 had been transferred from Hospital "A" because they did not have neurosurgery services. S2PA said she was consulted for neurosurgery and Patient #2 needed to have surgery, a lumbar fusion and a brace. S2PA said S6Neuro reviewed Patient #2's radiology films and asked her to transfer Patient #2 to Hospital "B". She said Patient #2 did not want to be transferred. S2PA said she told Patient #2 she would be transferred because she was stable and the group did not accept Medicaid patients for non-emergent cases. She said emergent was life or death and Patient #2 was not at risk of dying. In an interview on 4/12/17 at 9:10 a.m. with S7MD, he said he was working in the ED on the night of 11/17/16. S7MD said he accepted Patient #2 because the hospital had neurosurgery available and Hospital "A" did not. S7MD said the hospital had the capability and capacity to treat Patient #2. S7MD said he did not know why Patient #2 was transferred. In an interview on 4/12/17 at 9:55 a.m. with S3RN, he said he was working the night of 11/17/16 in the ED. He said Patient #2 had a T12 compression fracture. He said Patient #2 told him the S2PA told her she was being transferred because she was a Medicaid patient. He said he told the charge nurse S4RN. S3RN said he called S2PA and she confirmed that the patient was being transferred because she was a Medicaid patient. S3RN said he was not sure if transferring a patient because they were a Medicaid patient would be an appropriate transfer or not.

Based on record review and interview, the hospital failed to ensure all patients who presented to the hospital's emergency department (ED) were provided on-going stabilizing treatment for an emergency medical condition. This deficient practice is evidenced by failing to provide further stabilizing treatment for a fractured vertebra for 1 (#2) of 20 patients sampled when the hospital had the capacity and capability to treat the patient. Findings: Review of the Hospital Policy titled Triage and Medical Screening Exam, Serial Code ADM-01, revealed in part: 2. An EMC (emergency medical condition) is a condition with acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) that without immediate attention could result in: b. serious impairment to bodily function, c. serious dysfunction of any bodily organ. 6. The hospital will provide, without discrimination, care for emergency medical conditions to individuals regardless of whether they are Financial Assistance Policy eligible. A medical screening examination and appropriate emergency services will be provided to any individual regardless of diagnosis, financial status, race, color, national origin, religion, age, gender or disability in accordance with 42 CFR 489.24 (d) (4) and (5). Review of Patient #2's medical record revealed she had been accepted as an ED to ED transfer from Hospital "A"s emergency department on 11/17/16 at 8:51 p.m. because Hospital "A" did not have neurosurgery services available. Further review revealed Patient #2 was then transferred to Hospital "B" on 11/18/16 at 2:25 a.m. Review of Patient #2's medical record revealed a MRI radiology report from Hospital "A" dated 11/17/16 at 3:59 p.m. revealed the following: Clinical Indication: Back pain, bladder incontinence and lower extremity numbness status post recent fall. Findings: There is an acute appearing anterior compression fracture of the T12 vertebral body with approximately 50% loss of vertebral body height and adjacent bone marrow edema. There is T12 vertebral body fracture retropulsion causing moderate central canal stenosis just below the T11-12 level contacting and mildly deforming the adjacent distal cord without evidence of cord edema. Review of a progress note by S2PA (the on call neurosurgery PA) dated 11/17/16 at 10:00 p.m. revealed the following: [AGE] year old female status post fall on 11/1/16. Complains of immediate back pain and bladder incontinence started several days after. PCP sent her to the ER at Hospital "A" where lumber MRI was done showing T12 compression fracture with moderate canal stenosis. Decreased sensation left 2nd/3rd toes, foley catheter AIP: T12 compression fx 1) NSG recommendation is transfer pt to Hospital "B" for treatment. 2) pt refuses transfer due to family issues in Baton Rouge. 3) will order non custom TLSO brace. 4) Explained to pt that urinary incontinence can become permanent if she does not go to Hospital "B". Review of Patient #2's Transfer Record revealed the reason for transfer was to a higher level of care. Further review revealed the following statements: You are being transferred to another facility that has a particular service that you need for continued stabilization of your condition. We are currently unable to offer those services at this facility. The specialty service that you require is ortho-spinal. Review of Patient #2's nurses notes dated 11/17/16 revealed an entry by S3RN at 10:45 p.m.: Notified charge nurse S4RN of suspected EMTALA violation. Pt states, "They are transferring me because of my Medicaid, they told me so". 10:45: Was told by charge nurse S4RN, "We do this all of the time, don't worry about it". 10:45: Called neuro to verify this, spoke with PA who confirmed that she told the patient, "We are sending you to Hospital "B" because of your Medicaid. In a phone interview on 4/11/17 at 10:30 a.m. with Patient #2, she said she was embarrassed when S2PA told her they would not operate on her at Our Lady of the Lake Regional Medical Center because she was a Medicaid patient. Patient #2 said after she refused the transfer to Hospital "B", S3PA told her if she did not go to Hospital "B" she could be paralyzed so she changed her mind. Patient #2 said after she arrived at Hospital "B", she was admitted to the ICU and had spine surgery within 4 hours. In an interview on 4/12/17 at 7:35 a.m. with S5MD, he said he was an ED physician at the hospital and he was working the night Patient #2 had been transferred from Hospital "A". He said Hospital "A" did not have neurosurgery capacity. S5MD said they accepted Patient #2 because they had neurosurgery on call. He said S2PA came to the ED for neurosurgery on call and assessed Patient #2. He said S2PA indicated the patient needed further care and said it would be easier for her to go to Hospital "B". S5MD verified S6Neuro was capable of doing the type of surgery Patient #2 required. In an interview on 4/12/17 at 7:55 a.m. with S6Neuro, he said he was the neurosurgeon on call for the hospital on [DATE]. He said Patient #2 was transferred from Hospital "A" because she had a compression fracture and they did not have neuro coverage. S6Neuro said Patient #2 needed surgery for her injury. S6Neuro said he has a relationship with Hospital "B" and the environment was good for large cases. He said Patient #2's surgery would require a group of people to coordinate. He said it is good for the residents in training at Hospital "B". He said coordinating with other services at Our Lady of the Lake Regional Medical Center was complex because they had to coordinate the vascular service and the equipment company in the middle of the night and schedule the OR time. S6Neuro also verified he had the capability to do the surgery here at the hospital and had done the type of surgery she needed in the past. In an interview on 4/12/17 at 8:36 a.m. with S2PA, she said she worked for a neurosurgical group. S2PA said she was taking call with S6Neuro on 11/17/16. She said Patient #2 had been transferred from Hospital "A" because they did not have neurosurgery services. S2PA said she was consulted for neurosurgery and Patient #2 needed to have surgery, a lumbar fusion and a brace. S2PA said S6Neuro reviewed Patient #2's radiology films and asked her to transfer Patient #2 to Hospital "B". She said Patient #2 did not want to be transferred. S2PA said she told Patient #2 she would be transferred because she was stable and the group did not accept Medicaid patients for non-emergent cases. She said emergent was life or death and Patient #2 was not at risk of dying. In an interview on 4/12/17 at 9:10 a.m. with S7MD, he said he was working in the ED on the night of 11/17/16. S7MD said he accepted Patient #2 because the hospital had neurosurgery available and Hospital "A" did not. S7MD said the hospital had the capability and capacity to treat Patient #2. S7MD said he did not know why Patient #2 was transferred. In an interview on 4/12/17 at 9:55 a.m. with S3RN, he said he was working the night of 11/17/16 in the ED. He said Patient #2 had a T12 compression fracture. He said Patient #2 told him the S2PA told her she was being transferred because she was a Medicaid patient. He said he told the charge nurse S4RN. S3RN said he called S2PA and she confirmed that the patient was being transferred because she was a Medicaid patient. S3RN said he was not sure if transferring a patient because they were a Medicaid patient would be an appropriate transfer or not.

Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires that hospitals comply with 42 CFR §489.24, Special Responsibilities of Medicare Hospitals in Emergency Cases as evidenced by: 1) Failing to ensure all patients who presented to the hospital's emergency department (ED) were provided on-going stabilizing treatment for an emergency medical condition. This deficient practice is evidenced by failing to provide stabilizing treatment for a fractured vertebra for 1 (#2) of 20 patients sampled when the hospital had the capacity and capability to treat the patient (see findings tag A-2407); and 2) Failing to provide documented evidence to indicate an appropriate transfer was provided for 1 (#2) of 20 patients who presented to the hospital's ED with an emergency medical condition. This failed practice was evidenced by Patient #2 being transferred to another facility when the transferring hospital had the capability and capacity to provide services (see findings tag A-2409).

Based on record reviews and interviews, the hospital failed to meet the requirement of §489.24 as evidenced by: Failing to ensure for the appropriate transfer of psychiatric patients (evaluated to be a danger to self and/or others and placed on a Physician's Emergency Certificate) who were in need of acute inpatient psychiatric services of which the sending hospital was unable to provide at the time of transfer. This was evidenced by the hospital's failure to ensure 18 (#1, #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20) of 20 (#1- #20) psychiatric patients were transferred from the sending hospital to the receiving hospital by individuals who were appropriately trained and/or qualified to provide for the safe and effective transport of a patient in need of acute inpatient psychiatric services. The hospital allowed Company A to transport these patients using a single driver who had no training in medical and/or psychiatric emergencies and no training in the use of psychiatric de-escalation techniques. (see findings tag A- 2409).

Based on record review and interview, the hospital failed to ensure for the appropriate transfer of psychiatric patients (evaluated to be a danger to self and/or others and placed on a Physician's Emergency Certificate) who were in need of acute inpatient psychiatric services of which the sending hospital was unable to provide at the time of transfer. This was evidenced by the hospital's failure to ensure 18 (#1, #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20) of 20 (#1- #20) psychiatric patients were transferred from the sending hospital to the receiving hospital by individuals who were appropriately trained and/or qualified to provide for the safe and effective transport of a patient in need of acute inpatient psychiatric services. The hospital allowed Company A to transport these patients using a single driver who had no training in medical and/or psychiatric emergencies and no training in the use of psychiatric de-escalation techniques. Findings: Review of the hospital's policy titled Patient Transfer, revealed in part: 5. The patient's transfer will be by ambulance, air ambulance, or other transportation as deemed appropriate by the transferring physician. The attending physician has the responsibility to ensure that the transfer is effectuated through personnel with appropriate education, training and skill level, and appropriate equipment to maintain the designated level of care. Review of the contract between the hospital and Company A revealed in part: 1. Company A would provide secure one-way transportation for PEC patients of Hospital to any psychiatric and/or chemical dependent treatment facility within the state of Louisiana. 5. Violent patients have to be mildly sedated at time of pick up. 7. In the event of an emergency during transport, such as illness, Company A will notify the treating physician and hospital. Company A's staff will not and shall not be held responsible to administer first aid. 8. Company A is not responsible for the medical care of the patients of Hospital nor will Company A seek services other than for emergency care as warranted during transport. Patient #1 Review of the medical record for Patient #1 revealed he presented to the ED 7/02/16 with violent behavior and homicidal ideation. The patient was placed on a PEC (Physician Emergency Certificate). He was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 25-30 minutes. Patient #2 Review of the medical record for Patient #2 revealed he had arrived to the Hospital's Emergency Department on 7/28/16 at 10:29 a.m. by police escort with the complaint of Emotional Disturbance. Further review revealed he was transferred to a local psychiatric hospital on [DATE] at 10:50 p.m. Patient #2's transportation mode was Company A. The travel time to the receiving facility was approximately 15 minutes. Review of the PEC for Patient #2 dated 7/28/16 at 1:37 p.m. revealed the following: History of Present Illness: [AGE] year old AAM (African American male) presents in a psychotic/manic/ intoxicated state, BIB (brought in by) police in handcuffs, dressed in rainbow colored clothing, dancing and not able to communicate verbally in a meaningful manner. Mental condition: Psychotic/hostile/violent Patient is currently: Violent It is in my opinion that the above person named is in need of immediate psychiatric treatment in a treatment facility because he/she is seriously mentally ill or suffering from substance abuse so that he/she is dangerous to self, unwilling, dangerous to others, gravely disabled, unable to seek voluntary admission. Patient #4 Review of the medical record for Patient #4 revealed he presented to the ED 6/28/16 with agitation and auditory hallucinations. The patient was placed on a PEC. He was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 1 hour and 10 minutes. Patient #5 Review of the medical record for Patient #5 revealed he presented to the ED 6/24/16 with violent behavior, history of conduct disorder and explosive disorder. The patient was placed on a PEC. He was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 3 hours and 45 minutes. Patient #6 Review of the medical record for Patient #6 revealed she presented to the ED 7/01/16 on an OPC for bizarre and delusional behavior. The patient was placed on a PEC. She was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 25-30 minutes. Patient #7 Review of the medical record for Patient #7 revealed he presented to the ED 7/04/16 with violent behavior. The patient was placed on a PEC. He was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 1 hour and 30 minutes. Patient #8 Review of the medical record for Patient #8 revealed the [AGE] year old male presented to the ED 7/5/16 with violent behavior and homicidal ideation. The patient was placed on a PEC. He was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 3 hours and 45 minutes. Patient #9 Review of the medical record for Patient #9 revealed he presented to the ED 7/5/16 with violent behavior and suicidal. The patient was placed on a PEC. He was transferred to a local facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 15-20 minutes. Patient #10 Review of the medical record for Patient #10 revealed he presented to the ED 7/8/16 with agitation and violent behavior. The patient was placed on a PEC. He was transferred to a local facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 15-20 minutes. Patient #11 Review of the medical record for Patient #11 revealed she presented to the ED 7/15/16 with bizarre/paranoid behavior and auditory hallucinations. The patient was placed on a PEC. She was transferred to a local facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 15-20 minutes. Patient #12 Review of the medical record for Patient #12 revealed he presented to the ED 7/18/16 on an OPC with aggressive behavior. The patient was placed on a PEC. He was transferred to a facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 20-25 minutes. Patient #14 Review of the medical record for Patient #14 revealed she presented to the ED 7/11/16 with combative behavior and a history of dementia. The patient was placed on a PEC. She was transferred to a facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 20-30 minutes. Patient #15 Review of the medical record for Patient #15 revealed she presented to the ED 7/11/16 with violent behavior. The patient was placed on a PEC. She was transferred to a facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 15-20 minutes. Patient #16 Review of the medical record for Patient #16 revealed she presented to the ED 7/11/16 with manic behavior. The patient was placed on a PEC. She was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 15-20 minutes. Patient #17 Review of the medical record for Patient #17 revealed he presented to the ED 7/1/16 with violent and combative behavior, history of schizophrenia. The patient was placed on a PEC. He was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 10-15 minutes. Patient #18 Review of the medical record for Patient #18 revealed she presented to the ED 7/15/16 with complaints of assault (on herself), Alcohol abuse, and suicidal ideations. The patient was placed on a PEC. She was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 15-20 minutes. Patient #19 Review of the medical record for Patient #19 revealed he presented to the ED 7/16/16 with aggressive behavior, homicidal ideations, and history of Schizophrenia. The patient was placed on a PEC. He was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 15-20 minutes. Patient #20 Review of the medical record for Patient #20 revealed he presented to the ED 7/27/16 on an OPC, for violent behavior. The patient was placed on a PEC. He was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 15-20 minutes. In an interview on 8/5/16 at 1:30 p.m. with S3RN, she said when a psychiatric patient needed to be transferred the nurse would select the method of transfer which was usually Company A. S3RN said the physician did not select a mode of transfer. S3RN said the physician would sign the Certificate of Transfer which listed the mode of transportation. S3RN also said if Company A transferred a patient it was just a driver and the patient in the vehicle. S3RN said the car for Company A was like a cop car and had a cage between the front and back seats. S3RN said if the patient began acting out, the driver would pull on the side of the road and call EMS or go to the nearest ED. S3RN said there was no staff during transport to attend to the patient. In an interview on 8/5/16 at 4:50 p.m. with S7MgrCompany A, she said she was the Operations Manager for Company A. S7MgrCompany A said the drivers of the transport vehicles drove alone and their job was simply to transport patients. S7MgrCompany A said the drivers were not medical and did not have any training in patient care or how to handle psychiatric patients. S7MgrCompany A said the driver was only required to keep a visible eye on the patients. She said if the patients ran the driver did not chase them. S7MgrCompany A said if the patient began acting violently or hurting themselves during transport, the drivers would call the facility to come out and get the patient. S7MgrCompany A said if they were not near a hospital they would call the State Police to come get the patient. She said the driver could try to talk to the patients and calm them down but would never open the door to the back of the vehicle. S7MgrCompany A also verified the receiving hospital could sometimes be hours away from the sending hospital. In an interview on 8/8/16 at 9:00 a.m. with S5MD, he said he was the medical director for the behavioral health service line at the hospital. S5MD said psychiatric patients transferred were transported by a local ambulance company or Company A. S5MD said when patients were transported by Company A he was not sure of how many staff members were in the van with the patient or if the transporters could restrain patients. S5MD said he had not seen the contract between the hospital and Company A. S5MD said in the unit at the hospital the patients were directly observed at all times by staff. S5MD said that there was an abundance of caution because they were in an acute psychiatric facility for their safety. S5MD said the psychiatric patients were unpredictable and someone that had a PEC had a wide range of behaviors. S5MD said he agreed certain patients may not be safe during transport with a single driver without training. In an interview on 8/8/16 at 9:41 a.m. with S1Director, she said she was the Executive Director of Mental and Behavioral Health services at the hospital. S1Director said she did not know how many people were in the vehicle during transport by Company A or if they were trained. S1Director said she had never seen the contract. S1Director said the transferring facility was responsible for providing safety during transport. S1Director said it was the physician's decision as to the type of transport. In an interview 8/8/16 at 10:20 a.m. with S8Driver, he verified he was employed by Company A and said that he normally worked alone when he transported. S8Driver indicated that if he had a problem with a patient such as a medical one, or the patient was becoming violent or self-harming, he would drive to the nearest ED. S8Driver reported that he was not allowed to open the patient's car door. S8Driver reported that he has had to stop in the past at the nearest ED he could find because a patient was trying to harm themselves in the back seat. S8Driver said that he had patients that would bang their heads on the windows or screen and he had to divert to the closest hospital. S8Driver further indicated that even if he was in a remote area he still had to continue driving to the nearest hospital or pull over and call the state police. S8Driver also verified that the drivers had no specialized psychiatric training and were not required to have CPR. S8Driver said they strictly drove the transport vehicle. In an interview on 8/8/16 on 10:32 a.m. with S4MD, he said he was an Emergency Medicine physician. S4MD said when the psychiatric patients were ready for transport, the nurse would bring the transfer paperwork to the physician in the fast track area of the ER. S4MD said he is not sure why they bring the paperwork to them instead of the physician in the psychiatric unit. S4MD also said typically when the nurse sent the Certificate of Transfer for them to sign the mode of transport was Company A. S4MD said he was not sure how many people were in the Company A vehicles with the patients. He said he thought there were two or three staff in the vehicle. S4MD said he had not seen the contract and he was not aware if they had any type of training. S4MD agreed there was not continuity in care during the transport and maybe it was not safe. He said when he signed the Certificate of Transfer it was just for medical clearance. S4MD said someone in the psychiatric department determines the mode of transport but he is not sure who it is. In an interview 8/8/16 at 10:45 p.m. with S9RN, she said she was the ED Educator. S9RN reported that when someone was transferred from the facility (ED/EMBH) there was not an actual order written to transfer the patient or for the mode of transportation. S9RN indicated the nurses arranged transportation depending on the medical or physical needs of the patients. In an interview on 8/8/16 at 12:51 p.m. with S5MD, he said the COPE (Crisis Oriented Psychiatric Evaluation) team would set up the transfer method. S5MD said the COPE team was made of up counselors such as social workers. S5MD said the behavioral health portion of the ED did not have a requirement that the physician order the mode of transfer. In an interview on 8/8/16 at 1:50 p.m. with S6MD, he said he was the medical director of the ED. S6MD said the EMBH gets the ED physician's to sign a Certificate of Transfer when a psychiatric patient is going to be transferred. S6MD said by signing the Certificate of Transfer the MDs are agreeing with moving the patient to a higher level of care. S6MD says he and his physicians were agreeing with the information on the Certificate of Transfer when they signed it including agreeing the mode of transfer that was selected by someone in the EMBH. S6MD said he was not sure how many people were in the transportation vehicle for Company A or what type of training they had. S6MD said the organization (hospital) had selected this service so he assumed the staff was trained. S6MD said if he didn't know what services Company A provided and indicated that none of his physicians in the ED did either.