As directed by the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site allegation survey for the Emergency Medical Treatment and Labor Act (EMTALA), was conducted at the facility from 08/27/18 to 08/29/18, to investigate complaint MO 399 under the Responsibilities of Medicare Participating Hospitals in Emergency Cases, 42 CFR 489.20 and 489.24 (a)(e). The survey continued with telephone interviews on 08/30/18. The Hospital's Emergency Department (ED) average monthly census over the past six months was 2,281. The hospital failed to provide one patient (#5), an appropriate Medical Screening Examination (MSE) to determine that an Emergency Medical Condition (EMC) existed, when Patient #5, an inpatient in the Intensive Care Unit (ICU) for alcohol detoxification, left against medical advice (AMA) and returned to the hospital approximately one hour later. Patient #5 presented to the ED seeking care, "belligerent, intoxicated," and was not provided an appropriate MSE. The medical records did not include evidence that an MSE was completed, that staff explained the risks of refusal, or evaluated whether Patient #5 could understand the risks of refusal while belligerent, and intoxicated. Patient #5 was escorted out of the ED and off of the hospital property by security. Approximately one hour later, from concerns called into the hospital, Patient #5 was found by security in same location he was left, lying on the side of a street with his legs in the street. A second patient (#11) presented to the ED for mental status changes, was determined a danger to self/others, delusional (inability to tell what is real from what is imagined), paranoid (false belief that someone is trying to harm you), and a 96 hour involuntary detention (involuntary psychiatric admission for evaluation to determine psychiatric stability) was initiated. Patient #11 was transferred to Hospital B without the hospital's consent to accept the patient. The medical record did not include benefits that outweighed the risks of transfer (certified by physician), or confirmation that Hospital B accepted the patient, or had the capacity and capability to accept the patient. Please refer to the 2567 for details.

Based on interviews and record review, the hospital failed to provide a complete Medical Screening Examination (MSE) within its capacity and capability to determine if an Emergency Medical Condition (EMC) existed for one patient (#5) of 26 patients who presented to the hospital Emergency Department (ED) seeking care, out of sample selected from March 2018 to August 2018. Findings included: 1. Review of the hospital's undated policy, titled, "EMTALA (Compliance of Emergency Department and Hospital)", showed the following: - A MSE will be conducted to determine if the individual has an "emergency medical condition." It is unacceptable to transfer or discharge an individual directly to a physician's office for evaluation and/or treatment in lieu of affording the individual a "medical screening examination" within the hospital. - "Emergency Medical Condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absences of immediate medical attention could reasonably be expected to result in placing the health of an individual in serious jeopardy, or serious impairment to any bodily function of an individual. - "Appropriate Examination" means an examination beyond medical triage which is conducted by "qualified personnel" that is within the capability of the hospital, including ancillary services routinely available, to determine whether an "emergency medical condition "exists. - If a patient, or the person legally responsible for the patient, refuses to consent to an examination and/or treatment, the hospital will continue to communicate the hospital's willingness to afford an examination and treatment and will secure a written statement evidencing the individual's refusal to consent to examination and/or treatment. - If the individual refuses to sign a statement, document in the record the circumstances relating to the individual's refusal, including the refusal to sign a statement. Review of the hospital's undated policy titled, "Behavioral Health Assessment/Treatment-Emergency Department," showed the following: - Assess for behaviors, medical or psychological conditions that impact the patient's judgement, including dementia, alcohol and/or drug abuse. - Place the patient in a treatment room and obtain baseline laboratory testing. - Consult the ED Social Worker to assist with patient assessment, support, stabilization, and disciplinary care for inpatient admission or outpatient options. Review of Patient #5's inpatient medical record, dated 05/03/18 to 05/04/18, showed that he was a [AGE] year old male that presented to the hospital with a complaint of alcohol intoxication and requested alcohol detoxification. The patient reported drinking heavily for at least one year. The patient had a history of withdrawal seizures (seizures that occur from abrupt cessation of alcohol), and was admitted to the inpatient Intensive Care Unit (ICU, specialty area of the hospital that provides care by specially trained staff). On 05/04/18 the patient became upset, left the hospital, and later re-presented to the ICU. He appeared to be acutely intoxicated at that time. The physician informed him that he had already been discharged , and he would need re-evaluation in the ED. Review of the Hospital's ED log, dated 05/04/18, showed Patient #5 presented to the ED seeking care at 1:26 PM. Review of Patient #5's triage note, dated 05/04/18 at 1:26 PM, showed that the patient presented with complaints of wanting to be admitted for alcohol abuse. "The patient left the ICU an hour ago and went to drink, now returns wanting to be readmitted ." The patient's speech was slurred. Review of Patient #5's security report, dated 05/04/18 at 1:10 PM, showed that security had escorted Patient #5 to the ED after he was denied admittance to the ICU. On arrival to the ED the patient was triaged, and placed in an ED room. Staff R told Patient #5 he would not be treated, and asked security to escort Patient #5 from the hospital's property. Review of Patient #5's ED physician's note, dated 05/04/18 at 1:48 PM, documented by Staff R, ED Physician, showed that the ICU physician had called him and explained that the patient had left the ICU against medical advice (AMA), wanted to be readmitted , and directed Patient #5 to the ED. The patient was belligerent and uncooperative upon arrival to the ED. Staff R informed the patient that the hospital was not going to readmit him because he was noncompliant, because he had left the ICU AMA, and that he would be escorted by security, out of the ED and off of hospital property. Staff R consulted with the Social Worker in the ED. During a telephone interview on 08/30/18 at 12:30 PM, Staff L, Licensed Clinical Social Worker (LCSW), stated that she was the only LCSW in the ED on 05/04/18, and Staff R did not consult with her regarding Patient #5. During a telephone interview on 08/30/18 at 12:25 PM, Staff S, Registered Nurse, stated that Patient #5 presented to the ED for treatment of his alcohol abuse. The patient "appeared to be intoxicated, and had slurred speech." During an interview on 08/28/18 at 10:50 AM, Staff R, Physician, stated he was called by the ICU that Patient #5 had left AMA and was requesting re-admission. When the patient arrived in the ED, he was intoxicated, belligerent, and did not want to go through the ED again. He informed the patient that the hospital would not admit him any time he wanted to be admitted . Staff R did not order any laboratory test to determine level of intoxication, or continue the exam. He had security escort Patient #5 out of the ED and off of the property. Review of Patient #5's security report, dated 05/04/18 at 2:08 PM, security was contacted after patients complained about Patient #5 sitting along a street. Security investigated and found Patient #5 "asleep in the grass between the sidewalk and the street, with his feet and lower legs in the street." During an interview on 08/29/18 at 11:25 AM, Staff H, ED Director, stated that after review of Patient #5's ED record, dated 05/04/18, the record showed that the patient received an incomplete MSE. The medical record did not contain adequate documentation of a physical examination, ongoing recording of vital signs, use of all necessary available testing, discharge instruction, a willingness to afford an examination and treatment, and/or documentation of written refusal including risks and benefits, or whether the patient understood the risks and benefits. These failed practice had the potential to cause harm or death to Patient #5, who was escorted off of the hospital's property, in an intoxicated state, and was later found "sleeping" with his legs in the street.

Based on interviews and record review, the hospital failed to arrange an appropriate transfer for one patient (#11) with a psychiatric emergency, out of 26 patients who presented to the hospital Emergency Department (ED) seeking care, of a sample selected from March 2018 to August 2018. The facility discharged Patient #11 to Law Enforcement (LE) with instructions to transport the patient to another hospital. Findings included: 1. Review of the hospital's undated policy, titled, "EMTALA (Compliance of Emergency Department and Hospital)," showed the following: - If a patient has an emergency medical condition (EMC) which has not been "stabilized," then the hospital may "transfer" the individual if the patient, or person legally responsible for the patient, requests a "transfer" in writing after having been informed of the hospital's legal duty to treat the patient, or - The Emergency Department physician and/or other physician have determined that it was an "appropriate transfer". - The physician has determined that the benefits of the "transfer" outweigh the risks to the patient, and the physician has signed a certification of this fact. - The risks, benefits, and alternatives to "transfer" have been explained to the patient and/or person legally responsible for the patient and documented in the patient's medical record. - The receiving physician and hospital will be contacted to ensure that appropriate services, space, equipment, and qualified personnel are available to treat the patient and that the facility will accept the patient and this will be documented. Review of the hospital's undated policy titled, "Behavioral Health Assessment/Treatment-Emergency Department," showed to consult the ED Social Worker to assist with patient assessment, support, stabilization, and disciplinary care for inpatient admission or outpatient options. Review of Patient #11's (Hospital A) ED medical record, dated 08/13/18, showed that she was [AGE] year old female who presented to the ED by ambulance. The patient's husband had called their primary care physician and reported that the patient was having visual hallucinations (visualizing things that were not really present). "She is interacting with children playing in the yard, (who was not physically present) and was actually in the yard looking for them." The patient complained that she had not slept well for a long time, her husband has hit her, and she did not feel safe at home. She had a history of [DIAGNOSES REDACTED] (disease where the body produces insufficient amounts of hormones) and depression with anxiety. The provider noted that the patient had left her exam room and was found in the ED waiting room aggressive, paranoid (perceived threat towards oneself), and delusional (beliefs or judgements that are contradicted by reality). The provider noted that the patient was a harm to herself and others because of her aggressive behavior, polypharmacy (use of multiple drugs for treatment of a condition), delusions, hallucinations (perception of something not present), and paranoia. A 96 hour hold (court ordered evaluation for psychiatric risk) was initiated by the provider and the social worker. Review of Patient #11's "Affidavit in Support of Application for Involuntary Admission and Treatment (96 hour hold)," completed by Staff K, ED Nurse Practitioner, showed, "I am concerned for her safety. She is showing aggression, is delusional, and is having hallucinations, and is a safety risk to herself," and believed the patient would benefit from a psychiatric evaluation and intervention. Review of Patient #11's provider note, dated 08/13/18 at 8:31 PM, showed Staff K documented that Hospital B had beds. Review of Patient #11's provider note, dated 08/13/18 at 10:05 PM, showed Staff K documented that patient report was given to Staff M, ED Physician, who assumed care of the patient. Review of Patient #11's provider note, dated 08/13/18 at 1::05 AM, showed Staff M, ED Physician, documented that the patient was committed (96 hour hold initiated) to Hospital B, and walked with LE for transport. Review of Patient #11's "Physician Disposition Checklist for Psychiatric Patients", dated 08/13/18 at 9:55 PM, showed Staff K documented: - A MSE had been completed of the patient. - An EMC of a psychiatric nature existed. - The patient appeared to suffer from a mental disorder and presented a likelihood of serious harm to him/her or others. - It was not within the capabilities of the hospital's staff or facility to provide further examinations and treatment necessary to stabilize the patient's psychiatric conditions. - The patient's medical conditions were stabilized within the capabilities of the staff and facility. - Due to the patient's psychiatric needs, the hospital had attempted to transfer the patient to an appropriate psychiatric facility for further examination and treatment. - The hospital was unable to obtain a voluntary transfer to an accepting psychiatric facility due to patient's refusal to cooperate, as a result of the patient's psychiatric conditions/metal disorder. - The document was signed by Staff K. During an interview on 08/29/18 at 10:15 AM, Staff C, Professional Practice Manager, stated Patient #11's transfer was the first patient to be transferred with the new "Physician Disposition Checklist for Psychiatric Patients." She acknowledged that the new checklist did not have documentation of risk and benefits, or transfer requirements (which included confirmation that the receiving hospital accepted the patient and had the capacity and capability to stabilize the patient). During a telephone interview on 08/30/18 at 12:30 PM, Staff L, Licensed Clinical Social Worker (LCSW), stated that she called Hospital B and checked to see if there was a female bed. She did not confirm that the receiving facility would accept the patient, nor did she send the required patient transfer paperwork. During a telephone interview on 08/30/18 at 12:35 PM, Staff K, ED Nurse Practitioner, stated she verified that Hospital B had a female bed, but did not confirm that the hospital would accept the patient. During a telephone interview on 08/29/18 at 10:20 AM, Staff M, ED Physician, stated that the procedure was a new protocol for the transfer of 96 hour hold patients. Staff M verified with Hospital B that they had female bed, but did not confirm that the hospital would accept the patient, and did not sign attestation that confirmed Hospital B accepted care of Patient #11. During an interview on 08/29/18 at 11:25 AM, Staff H, ED Director, stated that after review of Patient #11's ED record, dated 08/30/18, the record showed that the patient was inappropriately transferred. Review of Patient #11's (Hospital B) ED medical record, dated 08/14/18, showed that Patient #11 was an unexpected transfer from Hospital A, was medically cleared, and admitted to the psychiatric center. Boone Hospital's medical record did not contain documentation of certification and authorization of transfer for Patient #11 to Hospital B. The medial record did not include documentation of the transfer requirements that the patient was accepted for transfer by the receiving facility, or that the receiving facility had the capability to admit and stabilize Patient #11.