Based on a review of emergency department logs, and behavioral health unit referral logs, it is revealed that; 1) ED log documentation for patient#1 is inaccurate; 2) BHU log reveals no outcome for referrals #11 and #12. Patient #1 was a middle-aged, developmentally disabled male who presented via car with a program staff member to the emergency department on 3/28/2016 at 1300. Patient #1 had a Quick Triage at 1521, and was given a level 4 Priority. He was asked to wait in the waiting room with his accompanying staff. When patient #1 was called at 1800, there was no answer. The staff member had taken him from the waiting room. Log documentation should reflect that he left without being seen. Instead, the log revealed a "RegError" (registration error). Patient #1 presented again on 3/29 at 1035. No ED log documentation reveals that patient #1 presented to the ED. However, patient #1 was seen and transferred to a higher level of care. Patient #1 does appear on the transfer log for 3/29. A behavioral health unit (BHU) referral log revealed that patients # 11 and #12 had no outcome information regarding a declination or acceptance to the BHU. Based on all findings, the hospital failed to keep complete and accurate emergency logs.

Based on a review of the Physician assistant job description, hospital policy and the hospital bylaws, rules and regulations, it is revealed that the Governing Body failed to approve who can conduct a medical screening examination. Based on a review of the hospital's PA-C job description, " Physician Assistant Scope of Practice " for Physician Assistant (PA) applicants, it was determined that, while the job description delineated PA duties, no assignment of authority for the medical screening examination was found. The job description read, in part: "Screen patients to determine need for medical attention; perform a physical examination; and initiate appropriate evaluation and emergency management for emergency situations; e.g., cardiac arrest, respiratory distress, injuries, burns, hemorrhage ... This document was approved by Board of Trustees in 1995. Further review of the hospital policy " Medical Screening Exam - EMTALA " (revised 7/14) revealed in part, " 2. The MSE (medical screening exam) will be conducted by the Emergency Department Physician or Physician Assistant under direct supervision of the ED Physician. " No Medical Staff approval of this policy is found. Finally, review of the hospital medical staff bylaws (approved 12/17/2015)) revealed that Allied Health Professionals comprised in part of Physician Assistants, " shall be eligible to provide specified services in the Hospital ...the prerogatives of an Allied Health Professional shall be to: provide specified patient care services within the area of his/her professional competence and as permitted by State licensure; ... " No provision found within the bylaws specifies that a PA may conduct medical screening examinations, nor do the bylaws or rules and regulations of the medical staff define which categories of physician or non-physician providers may perform the medical screening exam.

Based on a review of admission criteria for the behavioral health unit, the Emergency Department (ED) On Call Clinician Log (OCCL) for hospital ED psychiatric admissions, and the hospital behavioral health unit (BHU) log for admission referrals from other hospital emergency departments, it is revealed that 1) the hospital failed to note specific parameters regarding " Inappropriate for Admission " criteria for one exclusion; and 2) failed to admit patient #3, #4, # 8, #9, and #10,or specify the incapability of the unit. The hospital behavioral health unit admits voluntary and involuntary patients, a percentage of which are referred by other hospital emergency departments. Review of hospital policy, " Emergency Department - ED Admission of the Behavioral Health Patient (revised 9/15) revealed, that behavioral health patients determined to be appropriate for admission, were those who were: Medically stable: no oxygen or IV therapy Potential danger to self, others or property; Failed outpatient therapy; Impaired reality testing; Impaired social, familiar or occupational functioning; Court ordered observation; Planned detoxification ...(in conjunction with one or more of the above criteria) Further review of the policy revealed that those patients who would be inappropriate for admission in part had, " Self-destructive behavior beyond the capabilities of the Behavioral Health Unit. " No delineation of capability parameters for this exception to the BHU admission was found. Patient #3 was a middle-aged female who was referred by hospital B in August 2016 to hospital A BHU for involuntary admission. Patient #3 was psychotic, and had self-destructive behaviors, most recently, swallowing such things as coins batteries, and a razor blade. She had been determined by hospital B to have an emergency medical condition requiring inpatient treatment. At the time of referral, the BHU had 2 of 24 beds available for admissions, and no acuity issues such as seclusion or restraint. BHU log documentation revealed the reason for patient #3 being declined for admission as, " Acuity too high, can ' t meet patient needs. " No specifics related to how the BHU could not meet patient #3 ' s needs were noted. Patient #3 was referred a second time 4 days later by hospital B. At that time, the BHU had 2 beds available. BHU log documentation revealed the reason patient #3 was declined as " pt. (patient) too acute for unit per (psychiatrist). " Again, no specific information is found related to how the unit was incapable to meet the needs of patient #3. Patient #3 ' s behaviors had been determined to constitute an emergency medical condition. Patient #3 was a danger to self, and certified for involuntary admission. As such, patient #3 could only be admitted to an involuntary behavioral health unit that had a bed available. Based on both referral outcomes, the hospital failed to meet requirements for the recipient hospital when it failed to either admit patient #4, or specifically note how the unit was not capable to meet her needs. Patient #4 was a young adult male who was referred in August 2016 to the BHU at hospital A from the emergency department of hospital C. Patient #4 had hallucinations and made threats towards others, including threatening a friend with a knife. Patient #4 was reportedly noncompliant with medications. At the time of the referral, the BHU had 7 of 24 beds available, and no acuity issues such as seclusion or restraint. However, patient #4 was declined based on the scant documentation that the BHU, " Can ' t meet patient needs. " No further descriptors were noted regarding how the hospital was incapable of meeting patient #4 ' s needs, even though he met at least 5 of the hospital ' s policy criteria for admission. Based on the referral outcome, the hospital failed to meet requirements for the recipient hospital when it failed admit patient #4, or specifically note how the unit was incapable of meeting the needs of patient #3. Other findings on the OCCL revealed a reason why patient #8 and #9 were not admitted to the BHU due to, " Unit too acute. " The number of beds available were not listed on the log. Additionally, the BHU log revealed that with 3 beds available, patient #10 was not admitted due to " Acuity is high on unit. " Based on all documentation, the hospital violated their own BHU admission policy that delineated criteria for admission from both their own ED and referring ED ' s. Further, the BHU and OCCL logs failed to specify the incapability which justified declining patients who were found to have emergency medical conditions requiring inpatient treatment.