Based on records reviewed and interviews, the Condition Participation for Emergency Services was not met as evidenced by the failure to ensure care was provided in accordance with current standards for 1 of 20 sampled patients presenting to the Emergency Department (ED) (Patient #1). Finding: It is standard practice for all patients who seek care through the Emergency Department (ED) of a hospital to receive a thorough evaluation/assessment, stabilizing treatment, and discharge to home or to previous living environment in a stable condition, admission to the hospital for continuing treatment, or transfer to another hospital for further treatment that the hospital is unable to provide. The assessment and the medical decision making related to treatment and discharge should be documented in the record. Documentation in Patient #1's medical record indicated he/she presented to Hospital #1's ED, on 8/19/18 at 6:41 PM, with a chief complaint of mental health problems. On 8/19/18 at 6:41 PM, RN #1 documented the following: "Patient reports that [he/she] has been having suicidal ideations for many years S/T [status post] military status and PTSD [Post Traumatic Stress Disorder] issues. Pt [Patient] reports that what made it worse was that [he/she] had identified a plan for [himself/herself] today and then when these thoughts transferred to [his/her] family it made [him/her] concerned for their safety and to come to the ED." In the Suicide/Psychosocial Screening the following was documented: Experiencing Depression Yes. Suicidal Ideation/Attempts Yes. Homicidal Ideation /Attempts Yes. Alcohol/Drug Intoxication No. Hallucinations No. On 8/19/18 at 7:03 PM, RN #1 assessed this patient utilizing the "SAD PERSONS" assessment, which is an assessment that has a maximum score of 14. This assessment is utilized to determine if a patient is at low risk (score 0-5), in need of a psychiatric consult (score 6-8), or probably needs hospital admission (score over 8). Patient #1's total score was 7, which indicated the patient was in need of a psychiatric consult. Documentation in the patient's record indicated on 8/19/18 between 7:00 PM and 9:10 PM, the patient was on suicide precautions and one to one observations by an ED Tech/CNA [Technician/Certified Nursing Assistant]. At 7:00 PM and 7:15 PM, the ED Tech/CNA documented the patient was "resting" and from 7:45 PM to 9:10 PM documentation described the patient as "restless" and/or "agitated". On 8/19/18 at 7:38 PM, RN #2 documented, "Patient not wanting to talk about [his/her] story again got [him/her] to partially open up. Plan to use contractor bags and duct tape. Patient not making eye contact, looking away a lot. States history of traumatic brain injury from rocket and mortar blasts and PTSD from battle exposure." On 8/19/18 at 8:08 PM, ED Physician #1 documented the following: "ex-marine with PMI [Past Medical History] of TBI [Traumatic Brain Injury] from mortar and rocket fire arrives here for an evaluation of depression with SI [Suicidal Ideation]. Family reported to be concerned for the patient's safety. Patient declines interest in [Hospital #2] care or evaluation. Prefers local care including psychiatric"; "Pertinent negatives include no confusion, no agitation and no hallucinations. Mental status baseline is normal"; and under the Psychiatric Section of the Physical Exam, "[his/her] speech is normal and behavior is normal. Judgement normal. [His/Her] affect is blunt. Cognition and memory are normal. [He/she] expresses suicidal ideation." An order was entered into the record at 7:26 PM, by Physician #1, for a consult to Crisis Health, indicating the reason for the consult was "please assess for lethality and need for placement: hx [history] of TBI, depression, SI." Further documentation indicated Crisis Agency #1 intake contacted: case discussed. Clinician for assessment will be available between 10-11:00 hours tonight. At "20:50 [8:50 PM] patient was informed that the crisis consultant would be available between 22 [10:00 PM] and 23 [11:00 PM] hr [hours] tonight. Patient states this was not acceptable was not helpful. [He/she] was informed by nursing staff that there are no psychiatric beds available in the state. This knowledge of psychiatric bed status was from prior interaction with [Crisis Agency #1] consultant earlier today. The patient was offered an emergency department bed comfort with food and drink with observation until [Crisis Agency #1] assessment. Patient was dissatisfied with this. [He/she] was also dissatisfied with the fact that [he/she] was informed that there are no psychiatric beds available. I did offer to contact [Hospital #2] to see if there were psychiatric beds available there. Patient stated that [he/she] had a bad interaction with the [Hospital #2] system and therefore would not like to be associated with the [Hospital #2] system for [his/her] medical care. Patient stated [he/she] wanted to leave and [he/she] did not want to have a discussion on the difficulties in accessing the mental health system." Documentation by ED Tech/CNA at 9:10 PM indicated the patient left AMA (Against Medical Advice). No further written notes were documented in Patient #1's medical record. On 8/19/18 at 10:15 PM, Patient #1 presented to another hospital [Hospital #3] with a chief complaint of suicidal ideation. The physician at Hospital #3 documented the following: "Patient presents to the emergency department for evaluation of suicidal ideation. Patient notes that [he/she] has a history of suicidal ideation, anxiety, as well as PTSD. Patient notes that [he/she] was seen at [Hospital #1] earlier, was discharged after there not being an available bed for [him/her]. After being discharged , the patient went to a store, where [he/she] bought bags, as well as tape with the plan to asphyxiate [him/her] self." A wide variety of labs and a drug screen were ordered and arrangements were made for the patient to be transferred to Hospital #2 for psychiatric inpatient care on 8/20/18. On 10/10/18 and 10/11/18, a review of the Hospital #1's "Psychiatric Complaint" policy, last revised in 5/2017, was completed. This policy indicated the following: "Any patient presenting with psychiatric complaint (suicidal ideation, homicidal ideation, request for detox [detoxification], or deemed unsafe) will require a MSE [medical screening examination] by the ED provider and a psychiatric evaluation by [Crisis Agency #1] the triage and/or primary RN will order and send the following: CBC [Complete Blood Count], CMP [Complete Metabolic Profile], Alcohol Level, Urine Drug Screen, Urine Pregnancy, and place order for crisis evaluation." In reviewing Patient #1's record, there was no documentation that any of the required laboratory tests were ordered. On 10/10/18, a review of the Hospital #1's "Patients Leaving Against Medical Advice or Elopement" policy was completed. The policy indicated the following: " When a patient has made it known that he/she is choosing not to remain hospitalized or to say 'no' to medical treatment, the patient's physician and the Nursing Supervisor are to be notified of the patient's intentions. The physician and/or nurse will explain to the patient risks of refusing further treatment and the benefits of not leaving AMA. The nurse will request the patient to sign an AMA form.....If the patient refuses to sign the form, two staff members will sign as witnesses. The form will be scanned in the EMR [Electronic Medical Record]. Every effort will be made to provide the patient with discharge education (which the staff should have the patient sign if the patient is cooperative), follow-up appointments, prescriptions, etc. as appropriate. This provision of the above does not in any way imply that the facility is condoning the patient leaving AMA." In reviewing Patient #1's record, there was no documentation that the AMA form had been signed by the patient or scanned into the record. On 10/09/18 at 2:00 PM, ED RN #2, was interviewed. When asked if he thought this patient, who presented with SI and a suicide plan and required one to one observation, would be discharged home without a psychiatric evaluation, he paused for a few seconds and stated, "I didn't have a gut feeling [he/she] was going to go out and buy a gun or anything, although [he/she] is a Veteran so [he/she] probably has one, plus [he/she] didn't really have a plan." When it was pointed out that he had documented Patient #1 verbalized that [he/she] planned to use contractor bags and duct tape, ED RN#2 stated, "well, I really couldn't see [him/her] actually following through on that". When asked how often it was that a patient, who was placed on one to one suicidal watch and had an expressed plan, was discharged to home without being evaluated by a crisis agency, he stated, "it doesn't happened very often because most people come in wanting to get help" adding, "we don't blue paper people very often either because they usually come in asking for help". On 10/10/18 at 2:08 PM ED Physician #1 was interviewed. He stated the following: the patient had good eye contact, [he/she] was well groomed, [he/she] was well-spoken; he was left with a decision, do I physically restrain [him/her]?; he had to consider [his/her] lethality, intent, and stated plan; Do I violate [his/her] rights by tying /restraining [him/her], which could deter [him/her] from seeking treatment in the future; and this could escalate [him/her] knowing [his/her] history of PTSD, with possibly a violent outcome? ED Physician #1 shared that in his past work at Hospital #3 had experienced negative outcomes with similar situations, he had been assaulted, and patients/other staff had also been injured. He stated that if this person was delirious or didn't have good decision-making capabilities then this would be a different story; "I think this [man/woman] was very irritated with not getting an immediate evaluation"; he felt this patient was a capable decision maker with a history of PTSD, and was concerned with the risk of a violent outcome if he made [him/her] stay. When asked, "Would you have preferred that this patient had stayed ?", he stated "Yes, it would have been nice to get [him/her] into a crisis bed. [He/she] limited our availability to do so." He then repeated that he had to decide what risk out-weighed the other, giving [him/her] an ultimatum that [he/she] needed to agree to wait or be blue papered, and he felt this "violates [his/her] dignity." ED Physician #1 stated, he "did not feel [he/she] would follow out with the plan" and then stated he would have been devastated if he heard that after [he/she] left [he/she] had done something/following thru with [his/her] plan. Hospital #1 provided the surveyors with the "Department of Emergency Medicine Mortality and Morbidity Conference" minutes, dated 9/27/2018, which discussed Patient #1's 08/19/2018 presentation to the ED. It was documented that [Crisis Agency #1's] Psychiatrist "pointed out it would be illegal and harmful to 'blue paper' every patient who claimed to be suicidal and/or had a plan. He emphasized that involuntary committal is removing someone's civil rights, and is done only as a last resort and in case of imminent harm to self or others. He pointed out that he will sometimes use pointed questions to ascertain intent and that all three elements need to be present for a patient to be felt to be in imminent threat of completing suicide: 1. Do you at this moment feel death would be better than living? (Suicidality) 2. Do you have plans to follow through immediately? (Plan) 3. Do I need to worry that you are going to commit suicide tonight? (Intent) The treating physician felt that, based on his evaluation, the patient did not have intent and was not at risk of imminently completing suicide. Given that, he felt that respecting the patient's civil rights and desire to leave outweighed the minimal risk of actual self-harm." Based on the above information, on 8/19/18, Patient #1 presented to Hospital #1 with suicidal thinking and [he/she] expressed a plan to use contractor bags and duct tape to harm [himself/herself]. The hospital assessed the patient and determined that the patient was at risk and required a psychiatric consult. However, this patient did not have a psychiatric consult before [he/she] left against medical advice and there was no documented evidence that the risk of leaving against medical advice was considered before allowing the patient to leave. This patient left the hospital, went to a store, and purchased the things he/she had indicated in his/her plan (bags and duct tape). The patient then went to another hospital (Hospital #3) where he/she was evaluated to be suicidal and he/she was transferred, on 8/20/18, to Hospital #2 for inpatient psychiatric care. In addition, there was no evidence in the record that indicated the hospital ordered the tests indicated in their "Psychiatric Complaint" policy. The cumulative effect of the deficient practices resulted in noncompliance with this Condition of Participation.

Based on review of documents and interview, the hospital failed to ensure that the appropriate number of nursing personnel, identified in the nursing staffing plan, were on duty in the Emergency Department for 4 of 4 random days reviewed (8/3/18, 8/8/18, 8/19/18, and 8/25/18). Finding: On 10/10/18, the "St. Joseph Hospital Plan for the Provision of Patient Care, Nurse Staffing Plan and Contingency Plan Policy" was reviewed with the Director of the Emergency Department. This plan,in Section I b. iv. thru vii, described the daily staffing plan, as follows: "7:00 a.m. - 7 p.m. 3 RN's (Registered Nurses), 1 charge RN; 9:00 a.m. - 9:00 p.m. - 1 RN; 10:00 a.m. - 10:00 p.m. - 1 LPN (Licensed Practical Nurse); 12:00 p.m. - 12:00 a.m. - 2 RN's; 3:00 p.m. - 3:00 a.m. - 1 RN; 7:00 p.m. - 7:00 a.m. - 1 RN and 7:00 p.m. - 3:00 a.m. - 1 RN." Actual staffing for four random days was reviewed and staffing for these four days did not meet the identified staffing plan. The days were as follows: - On 8/3/18, there was no LPN present on the 10:00 AM to 10:00 PM shift. - On 8/8/18, one RN, instead of two RNs, came on duty for the 12:00 PM to 12:00 AM shift. - On 8/19/18, there was no LPN present on the 10:00 AM to 10:00 PM shift and no RN came on duty for the 3:00 PM to 3:00 AM shift. - On 8/25/18, there was no LPN present for the 10:00 AM to 10:00 PM shift and no RN came on duty for the 12:00 PM to 12:00 AM shift. On 10/10/18 at 3:15 PM, the Director of the Emergency Department confirmed these findings.

Based on observation and interview, the hospital failed to conspicuously post a sign (in a form specified by the Secretary) specifying the rights of individuals regarding Emergency Medical Treatment and Labor Act (EMTALA) statute in places likely to be noticed by all individuals seeking treatment in the Emergency Department (ED). The finding includes: On June 19, 2017, at approximately 9:12 AM, during a tour of the ED, the hospital's ambulance entrance was observed not to have any sign posted providing EMTALA notification for patients arriving by ambulance. This finding was confirmed by the ED Director on June 19, 2017 at approximately 9:12 AM. She stated "this entrance is sometimes used by walk in patients ... It makes sense to have an EMTALA sign in the ambulance entrance."

Based on document review and interviews, the hospital failed to provide an appropriate medical screening examination to a patient who arrived at the hospital seeking emergency treatment for 1 of 21 individuals reviewed (Patient #1). The finding includes: On June 12, 2017 at 2:45 p.m., the Division of Licensing and Certification received the following report from a hospital representative: On June 8, 2017 at 8:30 PM, an ambulance arrived at the hospital transporting a pediatric trauma case (Patient #1). The ambulance arrived in the hospital's ambulance bay and an Emergency Department (ED) Technician told the ambulance crew they needed to go to another hospital (Hospital B). The patient was not assessed before the ambulance left the hospital grounds. On June 19, 2017 at 9:38 AM, a telephone interview was conducted with the ED Technician who was on duty in the evening of June 8, 2017. The Technician reported the following events occurred: She was sitting in the nursing station when the hospital received a radio call from the ambulance; she answered the radio and was informed, by the ambulance attendant, that they were enroute with a six (6) year old trauma patient; two (2) Physicians were nearby and overheard the ambulance report; "I was asked by [the ED contract Physician] to defer the ambulance to [trauma center in same city]"; she went to the ambulance bay to inform the ambulance crew of the diversion decision; she stated "I was alone; the only St. Joe's staff member out there"; the patient was not removed from the ambulance and the ambulance was in the bay less than one (1) minute. She also she reported she had not received any EMTALA training prior to this event. On June 19, 2017 at approximately 11:45 AM, an interview was conducted with the ED Physician. The ED Physician reported the following: He verified he was on duty on June 8, 2017 and overheard the ambulance radio report; he discussed the case with the contract Physician working in the ED with him; this discussion included if this was an appropriate case for this hospital, which is not a trauma center; "I told the RN [Registered Nurse] to advise to divert over radio."; the Physicians were notified that the ambulance was already in the ambulance bay; the contract Physician reportedly grabbed his stethoscope and went out to the ambulance bay to assess the patient and the ambulance was already gone; "I knew it was a problem once [contract physician] came back in and said the ambulance was gone ...Giant red flag ... If they are on our property, they are our patient; and I followed up with my supervisor [ED Medical Director] regarding this at 8:43 PM on June 6, 2017, via email". On June 19, 2017 at approximately 12:20 PM, a telephone interview was conducted with the contracted ED Physician. The contracted ED Physician verified he was on duty on June 8, 2017 and overheard the ambulance radio report. "It was about 8:30 on June 8, 2017 ... I went out to the ambulance bay to see the kid ... the ambulance was gone ... it was my understanding that if a patient is on the premise, we treat them. Nobody said to not send the child; we only asked why they were bringing a kid here when there is a trauma center a mile down the road. When I heard about this, it was my understanding that that the ambulance was here". On June 19, 2017 at approximately 12:38 PM, an interview was conducted with the ED Charge Nurse. The ED Charge Nurse reported the following: On June 8, 2017 at approximately 8:30 PM, she was busy treating four (4) patients and was informed that an ambulance called and was coming in with a pediatric trauma patient; when she went out, the ambulance had come and gone; and it happened fast - all just a few minutes time. She reported that the ED Technician may take the ambulance call and then reports the information to the Charge Nurse. In this case, the hospital does not have inpatient pediatric department or pediatric trauma capabilities. "We were going to have to transfer this ped patient out if it were a true trauma". "We can ask an ambulance to divert if we don't have the capabilities to care for them, the physician makes that decision". The ambulance run sheet was reviewed. The report indicated the following: the patient's mother requested transport to this hospital; they gave report, via radio, approximately five (5) minutes before arriving at the hospital; the ambulance arrived at the hospital on June 8, 2017 at approximately 8:38 PM; "Before unloading the patient from the ambulance, a St. Joseph's nurse came out and strongly suggested [ambulance] to consider diverting the patient to [nearby trauma center]. They thought it would be most appropriate for the young patient to receive proper pediatric and trauma care ... EMS [ambulance] cleared St. Joseph's at 2039 [8:39 PM] ..." Based on the interviews conducted on June 19, 2017, the patient arrived on hospital grounds, via ambulance, for emergency care and the hospital failed to provide this patient with a medical screening examination before the ambulance was instructed to go to another hospital.