Based on review of hospital EMTALA (Emergency Medical Treatment and Labor Act) policies and record reviews the facility failed to ensure staff followed their policies to maintain compliance with EMTALA. The facility failed to ensure a central log was kept that included all obstetric patients presenting for a Medical Screening Examination with their disposition. See deficiency at A2405. The facility failed to have signage notifying patients of their rights under EMTALA at all entrances. The facility failed to ensure 1 (Patient 1) of 1 preterm labor patients with an unstabilized Emergency Medical Condition (EMC) was stabilized within the hospital's capability and transferred appropriately to minimize the risk to the patient and the unborn twins. See deficiency at A2409. Findings are: A. During the entrance conference for the EMTALA complaint investigation on 7/24/18 at 2 PM with administrative staff, the surveyors requested verbally and in writing the logs of emergency cases for the past 6 month (including those of obstetrics or other types of patients if logged separately from emergency cases). The facility promptly provided (on 7/24/18) the logs of patients presenting to the emergency department. After several requests on 7/24 and 7/25/18 the facility was unable to provide a log of obstetric patients who came in for a Medical Screening Examination and did not deliver or those that were transferred. The facility's obstetric log included only those patients who deliver. At 9:45 AM on 7/25/18 the facility provided a list of obstetric patients who transferred. The list included a [AGE] year old patient. Registered Nurse D confirmed the list was inaccurate. Interview with the Director of Nursing on 7/25/18 at 5:00 PM confirmed "we have a problem with the OB [obstetric] log/MSE". The DON said they used to have a log but it "fell through the cracks" when the facility's electronic medical record system changed. Review of a facility policy titled "Emergency Medical Treatment and Active Labor Act" effective date 2/1/16 stated "A log is maintained in the Emergency Department depicting any individual who seeks assistance in the form of emergency services and screening including the patient presenting for obstetrics screening." B. Observation during a tour of the hospital on [DATE] at 12:05 PM found no signage with notification of EMTALA rights at the main entrance to the hospital. Signage was not present at the North Admissions area. Interview with the Director of Family Care 7/26/18 during the tour confirmed the lack of signage at the main hospital entrance and the North Admissions areas. The Director stated that Labor and Delivery patients coming to the hospital from the physician clinics would use the North Admissions area. Review of the hospital policy titled "Emergency Medical Treatment and Active Labor Act" effective 2/1/16 stated "Conspicuous signage describing a patient's rights to examination and treatment for emergency medical conditions, women in labor and indicate the Hospital's participation in the Medicaid program will be posted at appropriate locations. C. Hospital record review showed Patient 1 (MDS) dated [DATE] for possible labor. Monitoring from 1:00 AM until 2:00 AM showed patient 1 was not having contractions during the visit. The Certified Nurse Midwife determined patient 1 was in false labor and discharged the patient at 2:00 AM. The patient returned to the Labor and Delivery unit on 7/12/18 at 5:09 PM. The patient was sent to the hospital from the OB (Obstetrical) physician's office. Documentation showed the patient's cervix (entrance to the uterus) had changed from closed to 1 centimeter (cm) dilation. During labor the cervix opens to 10 cm for delivery of the infant. Review of the OB Medical Doctor (MD) C's history and physical exam dated 7/12 at 5:47 PM noted this was the patient's third pregnancy with 1 living child born at term (40 weeks). The patient was due on 9/9/18 and was currently at 31 weeks and 4 days gestation (period from conception to birth, full term being 40 weeks). Review of progress notes dated 7/13/18 at 1:17 AM by MD C revealed the patient was complaining of increasing pelvic pressure and was having contractions every 3 minutes. MD C documented patient 1 was pre term labor "Now with increasing contractions and cervical change will plan transfer" to [Name of Hospital B] with a higher Level 3 Neonatal Intensive Care Unit (NICU) located in a metropolitan area 152 miles away. The patient was transferred with an unstabilized EMC while in labor without a licensed medical professional capable of monitoring and evaluating the patient. This placed the patient and her unborn babies at risk of emergency delivery and or death. During an interview on 7/26/18 at 10:00 AM, Doctor of Osteopathic Medicine (DO) A, Pediatrician and Medical Director of the Family Care Center including NICU stated he was not consulted on patient 1. DO A confirmed that "without question" they have the capability to stabilize the babies and transfer at that gestational age (31 weeks, 4 days). DO A stated "we have delivered babies at this age and then transported, and on occasion have kept them here." "Usually at 32 weeks or less we will transfer after stabilizing." DO A stated they use the Guidelines for Perinatal care. Review of the facility policy titled "Emergency Medical Treatment and Active Labor Act" effective date 2/1/16 defines Labor as "The process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman having contractions is in true labor unless a physician certifies that, after a reasonable time of observation, the woman is in false labor. Except in the case of certified false labor, a pregnant woman experiencing contractions is legally unstable until delivery of baby and placenta." The policy further states that "In the event of pregnancy with contractions present, consistent with Maternal Child Unit policies and procedures, Mary Lanning Healthcare delivers the baby and placenta, except in cases where the benefits outweigh the risks that may arise from or during transfer." Patients are treated at the hospital unless "the required care cannot be provided" by the hospital. Under the section titled " Hospital to Hospital Transfers" the policy states the hospital may transfer a patient who has no reasonable risk of deterioration in condition from or during transfer to another facility." Before transfer the policy states the hospital "must provide treatment within its capacity to minimize the risks to the patient and/or unborn child." The policy defines an "appropriate transfer" one that is provided through qualified personnel and transportation equipment as required, including the use of necessary and medically appropriate life support measures during transfer, as determined by the transferring physician. Refer to tag A2409 for details.

Based on observations, staff interview and review of the facility policies for signage the facility failed to have the required EMTALA (Emergency Medical treatment and Labor Act ) signage specifying the patient's right to a medical screening examination and treatment of emergency medical conditions including patients in labor and whether the facility participates in the Medicaid program. Failure to have proper signage has the potential for patients leaving with Emergency Medical Conditions or in Labor due to lack of financial resources. Findings are: A. Observation during tour of the hospital on [DATE] at 12:05 PM found no signage with notification of EMTALA rights at the main entrance to the hospital. Signage was not present at the North Admissions area. B. Interview with the Director of Family Care 7/26/18 during tour confirmed the lack of signage at the main hospital entrance and the North Admissions areas. The Director stated that Labor and Delivery patients coming to the hospital from the physician clinics would use the North Admissions area. C. Record review of the hospital policy titled "Emergency Medical Treatment and Active Labor Act" effective 2/1/16 states "Conspicuous signage describing a patient's rights to examination and treatment for emergency medical conditions, women in labor and indicate the Hospital's participation in the Medicaid program will be posted at appropriate locations".

Based on information provided upon request for patients presenting for obstetric screening, staff interview and review of facility policy the facility failed to have a central log of patients presenting to the hospital for obstetric screening which included those requiring transfer to other hospitals. Failure to have a central log of all patients presenting for a Medical Screening Examination prevents the facility from being able to track the care and disposition of all patients who come to the hospital seeking emergency care. Findings are: A. During the entrance conference for the EMTALA complaint investigation on 7/24/18 at 2 PM with administrative staff a request was made verbally and in writing for the logs of emergency cases for the past 6 months including those of obstetrics or other types of patients if they are logged separately from emergency cases. The facility promptly provided on 7/24/18 the logs of patients presenting to the emergency department. After several requests on 7/24 and 7/25/18 the facility was unable to provide a log of obstetric patients who came in for a Medical Screening Examination and did not deliver or those that were transferred. The facility obstetric log includes only those patients who deliver. At 9:45 AM on 7/25/18 the facility provided a list of obstetric patients who transferred. On the list was a [AGE] year old patient. Registered Nurse D stated the list was inaccurate as the [AGE] year old was in a bed on the obstetric floor and transferred. B. Interview with the Director of Nursing on 7/25/18 at 5:00 PM confirmed "we have a problem with the OB [obstetric] log/MSE". The DON said they used to have one but it "fell through the cracks" when the facility electronic medical record system changed. C. Record review of facility policy titled "Emergency Medical Treatment and Active Labor Act" effective date 2/1/16 states "A log is maintained in the Emergency Department depicting any individual who seeks assistance in the form of emergency services and screening including the patient presenting for obstetrics screening".

Based on record reviews, staff and physician interviews, paramedic interview and review of facility policies and procedures the facility failed to provide 1 (Patient #1) of 1 pregnant patients, expecting twins with preterm labor an appropriate transfer. The patient had an Emergency Medical Condition (EMC) that was not stabilized within their capability and failed to provide a transfer with adequate trained personnel to minimize the risk to the patient and her unborn twins. The facility had the capability to deliver the twins safely. The hospital's capabilities included a Level 2 Neonatal Intensive Care Unit (NICU) capable of stabilizing and then transferring preterm babies, if indicated. The facility transferred patient 1 by ground ambulance with only a paramedic accompanying the patient, placing the patient and unborn twins at risk for early delivery and/or death during a 152 mile ambulance trip to another hospital. The hospital delivers on average 86 patients per month for the past 6 months. The Emergency Department sees on average 1,258 per month for the past 6 months. The total sample was 20 medical records. Findings are: A. Hospital record review showed Patient 1 (MDS) dated [DATE] for possible labor. Monitoring from 1:00 AM until 2:00 AM showed she was not having contractions. The Certified Nurse Midwife determined the patient was in false labor and discharged her at 2:00 AM. The patient returned presenting to Labor and Delivery on 7/12/18 at 5:09 PM. The patient was sent to the hospital from the OB (Obstetrical) physician's office. The patient's cervix (entrance to the uterus) had changed from closed to 1 centimeter (cm) dilation. During labor the cervix opens to 10 cm for delivery of the infant. Review of the OB Medical Doctor (MD) C's history and physical exam dated 7/12 at 5:47 PM noted "this is her third pregnancy with 1 living child born at term (40 weeks)." The patient was due 9/9/18 and was currently at 31 weeks and 4 days gestation (period from conception to birth, full term being 40 weeks). The pregnancy was complicated by twins each with their own amniotic (fluid sac) and umbilical chord. Patient 1 also has a history of spontaneous miscarriage 10/1/17 of a 6 week old fetus. Other medical history included asthma, Bipolar 1 (a psychiatric disorder with at least one manic episode), mild mental retardation. MD C noted the plan for care was to monitor the patient for preterm labor. "If continued contractions will proceed with Mg [Magnesium Sulfate a drug given IV (intravenously) to slow or stop premature labor] and steroids [a medication to speed development of the baby's lungs to prevent respiratory problems with premature birth]. Reviewed plan if labor progresses, would recommend delivery by LTCS (Low transverse Cesarean Section - a surgical opening into the uterus to deliver the babies). External fetal monitoring and tocometry was ordered continuously. This device monitors each babies heart beat and response to contractions of the uterus. Contractions are monitored for time, amplitude and frequency. Vital signs were monitored and were normal throughout the hospital stay. Review of Nurses Notes 7/12/18 at 6 PM noted uterine irritability (small frequent irregular contractions). MD C performed a vaginal examination of the patient at 6:05 PM noting that the patient was dilated to 1 cm, was 40 % effaced (effacement is thinning of the cervix with 100% at full dilation of 10 cm), and -4 station (determination of lowest part of baby in relation to the ischial spines of the pelvis, scored from -5 not engaged, 0 engaged and aligned with the pelvis and + 4-+5 at time of vaginal delivery). The membranes were intact with no leaking amniotic (fluid surrounding the baby). Fetal heart tones were normal for both babies. Magnesium Sulfate 4 Gram IV bolus was given at 6:34 PM followed by an infusion at 2 Grams per hour. A Foley catheter was inserted to keep the bladder drained at 6:40 PM. Betamethasone 12 milligrams (mg), a steroid, was given at 7:30 PM. IV antibiotic was given at 7:58 PM to prevent infection. Review of the external fetal monitor and contractions at 00:44 AM on 7/13/18 showed the patient's contractions were becoming more defined and regular. MD C was notified of the uterine activity and requested the nurse to perform a vaginal exam. At 1:10 AM Registered Nurse (RN) G did a vaginal exam which showed the patient was progressing in labor with the cervix now open to 3 cm and 60 % effaced. The membranes remained intact and there was no vaginal bleeding. At 1:15 AM the contractions were occurring every 1 - 2 minutes and lasting 60-100 seconds. Fetal heart tones were normal with normal response to contractions. Review of progress notes dated 7/13/18 at 1:17 AM by MD C revealed the patient was complaining of increasing pelvic pressure, had no loss of fluid or vaginal bleeding. The patient was having contractions every 3 minutes. Assessment was pre term labor. Cervical change with regular contractions represents a patient in labor, an EMC. The note stated the patient had an ultrasound today which confirmed the first fetus was in the vertex (head down) position. MD C documented that "Now with increasing contractions and cervical change will plan transfer to [Name of Hospital B with a higher Level 3 NICU located in a metropolitan area 152 miles away]. Advanced acceptance by a physician was obtained., RN G documented at 2:40 AM that MD C was updated on the cervical exam . The receiving hospital had accepted the transfer and the House Supervisor arranged transport via ground (ambulance). The contracted transfer service could provide transport by a helicopter, fixed wing air plane with a Registered Nurse and flight crew, or a ground ambulance with a paramedic and driver. The facility form titled "Certificate of Transfer" dated 7/13/18 documented the patient's condition as "the patient is pregnant with contractions present." Reason for transfer was "for equipment or services not available at this facility NICU." The medical risks for transfer was left blank. MD C signed the physician certification certifying that the risks of transfer were outweighed by the benefits reasonable expected from proper care at the receiving facility. Mode of transport was documented as Basic Life Support ambulance (an error as the ambulance included the services of a paramedic). A paramedic is trained in emergency delivery but is unable to monitor/evaluate the progression of labor or assess the fetuses response to contractions. The RN removed the fetal monitor at 2:12 AM which showed the patient having a contraction just before the monitor stopped. The patient was transferred with the Magnesium Sulfate infusing at 2 Grams per hour, IV solution of Lactated Ringers at 75 cubic centimeters (cc) per hour. The patient was transferred with an unstabilized EMC while in labor without a licensed medical professional capable of monitoring and evaluating the patient and unborn twins. This placed the patient and babies at risk of emergency delivery and/or death. Review of the ambulance transfer record documented by Paramedic F noted the ambulance left the hospital at 2:48 AM. Twelve (12) minutes later at 3:00 AM the record noted the patient stated she was having "contractions that started just as soon as the previous one ended." "She was also complaining that she was starting to have pressure and she was leaking." She was asked if her water broke and she said it had not. Paramedic called his Physician who provided Medical Control (located in another state) and was told to increase the Magnesium Sulfate drip to 100 cc per hour (4 Grams per hour) to slow the contractions. At 3:06 AM paramedic F decided to divert the ambulance to the closest hospital. There was no slowing of the contractions. At 3:36 AM the ambulance arrived at Hospital C. Review of Hospital C medical record, History and Physical dated 7/13/18 noted the patient was having contractions every 2-3 minutes, cervix dilated to 4 cm, 60 % effaced and a -2 station (showed the baby progression into the pelvis). Bedside Ultrasound showed Baby A to be in the vertex position and baby B to be breach (bottom down). The patient underwent a Cesarean section at 5:19 AM and the babies were taken to Hospital C's Level 2 NICU (same capabilities available at Mary Lanning Healthcare). B. During a telephone interview on 7/25/18 at 12:05 PM, House Supervisor RN E stated she arranged the transfer of Patient 1 on 7/13/18. She called [name of contracted service and was told they had a Fixed Wing (plane with RN included in flight team) available in 1 hr 9 minutes or a ground available in 20 minutes. RN E informed MD C of the two choices and times. MD C told RN E ground was ok with no nurse. RN E stated she relayed the cervical change from 1 to 3 cm to the transfer team. RN E confirmed the hospital kept a surgery team on call and could perform emergency Cesarean sections. RN E confirmed they could have delivered the babies and stabilized them until transport to a higher level of care, if needed. . C. During an interview on 7/26/18 at 10:00 AM, Doctor of Osteopathic Medicine (DO) A, Pediatrician and Medical Director of the Family Care Center including NICU stated that he was not consulted on patient 1. DO A confirmed that "without question" they had the capabilities to stabilize the babies and transfer to a higher level of care if indicated. DO A stated "we have delivered babies at this age (31 weeks, 4 days) and transported, and on occasion have kept them here." Usually at 32 weeks or less we will transfer after stabilizing. DO A stated they use the Guidelines for Perinatal care. D. Review of the facility policy titled "Emergency Medical Treatment and Active Labor Act" effective date 2/1/16 defines Labor as "The process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman having contractions is in true labor unless a physician certifies that, after a reasonable time of observation, the woman is in false labor. Except in the case of certified false labor, a pregnant woman experiencing contractions is legally unstable until delivery of baby and placenta." The policy states that "In the event of pregnancy with contractions present, consistent with Maternal Child Unit policies and procedures, Mary Lanning Healthcare delivers the baby and placenta, except in cases where the benefits outweigh the risks that may arise from or during transfer." Patients are treated at the hospital unless "the required care cannot be provided" by the hospital. Under the section titled " Hospital to Hospital Transfers" the policy states the hospital may transfer a patient who has no reasonable risk of deterioration in condition from or during transfer to another facility". Before transfer the policy states the hospital "must provide treatment within its capacity to minimize the risks to the patient and/or unborn child". The policy defines an "appropriate transfer" one that is provided through qualified personnel and transportation equipment as required, including the use of necessary and medically appropriate life support measures during transfer, as determined by the transferring physician. E. Based on the regulatory required physician peer review performed by the Quality Improvement Organization (QIO) KEPRO on 8/10/18, the hospital attempted to stabilize Patient 1's EMC, however the patient's labor continued to progress. On 7/13/18 at 00:44 Patient 1 was dilated to 3 centimeters and 60 % effaced with complaints of increasing pelvic pressure and contractions every 1 - 2 minutes. The OB/ GYN, MD C documented preterm labor at 1:17 AM on 7/13/18. The medical benefits of transferring the patient 152 miles away by ground ambulance without the ability to medically intervene was not safe and did not outweigh the medical risks. The hospital had a Level 2 NICU and could have delivered the twins and transferred later to a higher level of care.

An unannounced onsite EMTALA (Emergency Medical Treatment and Labor Act) investigation began on 9/22/16 and continued through 9/28/16. Based on record review, review of the facility EMTALA policies, staff interview and medical staff interviews the facility failed to perform an adequate Medical Screening Examination (MSE) for 1 (Patient 20) of 30 sampled patients to determine if the patient had an Emergency Medical Condition which required stabilizing treatment before a safe discharge. This failure posed an immediate and serious threat to Patient 20's health and safety. Patient 20 came to the Emergency Department (ED) on 6/14/16 due to psychiatric problems. During the initial screening of Patient 20's vital signs the blood pressure (BP) was elevated with a finding of 187/119, the blood pressure remained extremely elevated throughout the stay without the facility staff making mention of the elevated blood pressure. The facility discharged the patient with a blood pressure of 196/138 without providing treatment or education prior to dismissal related to the elevated blood pressure and the need to follow up with a health care practitioner. The lack of providing the patient with treatment and/or education regarding the elevated blood pressure put the patient at risk for the side effects of an extremely high blood pressure. Findings are: A. Medical Record Review of the ED visit on 6/14/16 for Patient 20 revealed the patient came to the ED at 9:18 AM. The Triage Notes identified that the patient reported "thoughts of paranoia, and feeling disconnected with thoughts of suicide with no plan." Initial vital signs were: BP 187/119, Temperature (T) 98.2 oral, Pulse (P) 106, Respirations (R) 24 and oxygen saturation 96% on room air, and currently takes no medications. The record identified Patient 20's past medical history of [DIAGNOSES REDACTED] The MSE (Medical Screening Exam) was completed by the Doctor of Osteopathic Medicine (DO)-B. The exam noted that Patient 20 presented with a chief complaint of psychiatric problems. The onset was one week prior to arrival. The patient denied any hallucinations, had unclear thinking, denied suicidal or homicidal thoughts. The patient is not uncooperative. The review of symptoms included: Respiratory: lungs clear and breath sounds were equal bilaterally, CV (Cardiovascular): Tachycardia (fast heart beat), the rhythm was regular. Neurological: oriented to person, place and time. The patient was awake and alert, memory was intact. Psychiatric: no visual or auditory hallucinations. The orders included: Blood Alcohol, CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), Lipid Panel, Protime/INR, TSH (Thyroid Stimulating Hormone), UA and UA for drug screen (unable to void before discharge), Hgb A1C, BP monitor per protocol, Mental health consult per protocol and Suicidal precautions per protocol. IMPRESSION: PSYCHOSIS (a lack of understanding with reality). DO-B documented "The patient was discharged to Home. The patient's condition upon discharge was good. Education was provided to the patient in reference to the impressions, diagnostic study results, treatment, prognosis and need for follow up. Instructions given to the patient: Psychosis. Follow up: As recommended by psych." DO-B's documentation lacked mention of the elevated blood pressures. The evaluation for Mental Health was completed by LMHP (Licensed Mental Health Practitioner)-I on 6/14/16 at 10:45 AM. Patient 20 was identified as denying suicidal thoughts or thoughts of hurting others, denied hallucinations, does experience paranoia related to minorities and homosexuals, and delusions "Gotta be alive in 2029 for the asteroids." Is homeless and resides in (gender) car, travels the United States, is on disability and has a medical history of [DIAGNOSES REDACTED]. An evaluation by the Psychiatrist/LMHP and in coordination with the ED doctor is completed to determine if an Emergency Medical Condition (EMC) for Mental Health exists. For Patient 20, it was felt that Patient 20 did not have an EMC for Mental Health and it was recommended to follow up with out patient psychiatric referrals (address and phone number provided) upon dismissal. B. Review of Patient 20's "Tabular Trend" form with BP's and Pulses recorded while in the ED revealed: 09:17 AM- BP 187/119, P 106 09:20 AM- BP 214/153, P 100 09:21 AM- BP 228/145, P 102 09:30 AM- BP 221/145, P 101 09:40 AM- BP 202/141, P 97 09:50 AM- BP 202/123, P 85 09:52 AM- BP 205/125, P 87 10:00 AM- BP 206/159, P 96 10:20 AM- BP 196/138, P 92 C. An interview with Registered Nurse (RN) H on 9/27/16 at 11:35 AM confirmed being the nurse caring the for Patient 20 during the 6/14/16 ED visit. Upon request of reviewing the documented BP's on Patient 20's record, RN H verified that the record lacked documentation of physician notification of the elevated BP's and lacked any dismissal instructions regarding following up about the BP's or printed information given about elevated BP's. RN H stated, "I usually chart if there is a high BP that I notified the doctor before they are discharged . But I don't see it anywhere in here." RN H verified that no medications were administered to Patient 20 during the ED visit. When RN H was asked if (gender) felt that it appeared Patient 20 had a hypertensive EMC? RN H stated, "Yeah" When asked if (gender) felt that Patient 20 was safe to send home when discharged , RN H stated, "No, I don't see it on the health history or a history of high BP." Do you feel Patient 20 then had an EMC at the time of Discharge? RN H stated, "Yes, due to the high blood pressure and without being on meds or a history." D. An interview with The Medical Director of ED (MD)-C on 9/28/16 at 9:05 AM regarding Patient 20, (due to DO-B is no longer employed at the facility and not available for interview) revealed the opportunity to review the 6/14/16 record. When asked if MD-C felt Patient 20 had an EMC for Mental Health, MD-C stated "No." When asked about the elevated BP's ranging from 187/119-214/153 during the ED visit if MD-C felt that Patient 20 had an EMC Medically related to the BP's, MD-C stated, "No." MD-C stated, "With (gender) labs (essentially normal), no chest pain, no shortness of breath and (gender) renal function was fine, the patient can follow up as an outpatient. According to the ACEP (American College of Emergency Physicians) it says if the patient is asymptomatic they can follow up as an outpatient. So on discharge give the outpatient information for blood pressure and outpatient information." MD-C verified that the discharge instructions lacked paperwork about blood pressure and there was not a follow up for the blood pressure issues mentioned. "I do see the discharge instructions say to follow up with psychiatric treatment." An address and phone number was listed for that on the discharge paperwork. When asked if MD-C felt that Patient 20 had a Medical EMC related to the elevated blood pressures at discharge, MD-C stated, "No, (gender) was asymptomatic and per ACEP (Patient 20) could follow up as an outpatient. However the discharge instructions should have had follow up referral information about the blood pressure on it." E. Record review of the facility policy titled "EMTALA" effective 2/1/2016 identified under title "A medical screening examinations is provided to any person presenting themselves anywhere on the campus who is seeking emergency services to determine whether that person has an emergency medical condition. An Emergency Medical Condition is defined in the policy as "As defined by law is a condition manifesting itself with acute symptoms of [DIAGNOSES REDACTED]. Emergency medical conditions always include women in labor, patients with substance abuse or current intoxication, patients with severe pain, and psychiatric patients that might or could ultimately be at risk to self or others." F. Review of the ACEP website -Current Clinical Policies Management- Asymptomatic Elevated Blood Pressure Volume 62 No 1 dated July 2013 revealed: -In patients with asymptomatic markedly elevated blood pressure, does ED medical intervention reduce rates of adverse outcomes? For patient management recommendations, Level A and Level B recommendatins- none specified; Level C recommendation was: (1) In patients with asymptomatic markedly elevated blood pressure, routine ED Medical intervention is not required. (2) IN SELECT PATIENT POPULATIONS (EG. POOR FOLLOW-UP), EMERGENCY PHYSICIANS MAY TREAT MARKEDLY ELEVATED BLOOD PRESSURE IN THE ED AND/OR INITIATE THERAPY FOR LONG-TERM CONTROL. [CONSENSUS REMMENDATION] (3) PATIENTS WITH ASYMPTOMATIC MARKEDLY ELEVATED BLOOD PRESSURE SHOULD BE REFERRED FOR OUTPATIENT FOLLOW-UP. [CONSENSUS RECOMMENDATION] Patient 20 is homeless and lives in (gender) car and travels the United States. G. Review of the Mayo Clinic website- High Blood Pressure article dated 9/9/2016 revealed the following categories to classify blood pressure: -Normal blood pressure- when the blood pressure is normal if below 120/80 mmHg (millimeters of mercury) -Prehypertension- Prehypertension is a systolic (top number-measures your arteries when your hear beats) pressure ranging from 120-139 mmHg or a diastolic (lower number-measures the pressure in your arteries between beats). -Stage 1 hypertension- Stage 1 hypertension is a systolic pressure ranging from 140-159 mmHG or a diastolic pressure ranging from 90-99 mmHg. -Stage 2 hypertension- More severe hypertension, stage 2 hypertension is a systolic pressure of 160 mmHG or higher or a diastolic pressure of 100 mmHg or higher. Uncontrolled high blood pressure can lead to: heart attack or stroke, aneurysm, heart failure, weakened and narrowed blood vessels in the kidneys, thinkened, narrowed or torn blood vessels of the eyes, metaboli[DIAGNOSES REDACTED], trouble with memory or understanding.

An unannounced onsite Emergency Treatment and Labor Act (EMTALA) investigation began on 9/22/2016 and continued through 9/20/2016. Based on medical record review, review of the facility EMTALA policies, staff interviews and physician interview the facility failed to ensure 1 (#12) of 7 sampled patients who were transferred for further stabilizing treatment were transferred by an appropriate method with qualified personnel present to prevent potential further risk to the patient's health and safety. This failure posed an immediate threat to Patient 12's health and safety. Patient 12, a minor was brought to the Emergency Department (ED) on 7/10/16 and was found to have an Emergency Medical Condition related to suicidal attempt. The patient was transported by parent's private vehicle for direct admission to an acute care hospital providing adolescent psychiatric services. The total sample size was 30. Findings are: A. Record review of Patient 12's medical record revealed the patient, a minor adolescent, was brought to the ED on 7/10/16 at 8:35 PM. The nursing documentation on arrival reveals the mother told the nurse the patient had been overdosing with an insulin pump. The patient is a diabetic and uses the insulin pump to infuse insulin through a subcutaneous site on a continual basis. The pump is programmed to deliver a continual rate of insulin and also a bolus or extra insulin to cover the consumption of carbohydrates to keep blood sugars in normal range. The American Diabetes Association defines target blood glucose (sugar) goals as 70-130 before meals and less that 180 after meals. The infusion of too much insulin can result in [DIAGNOSES REDACTED] (low blood glucose) that can result in a variety of symptoms ranging from clumsiness, trouble talking, confusion, loss of consciousness, seizures or death. The mother reported the patient had a history of suicidal intention. Humulog per Drug.com at www.drugs.com/humalog.html is identified as the insulin used by the patient. Humulog is used in insulin pumps to infuse insulin into the subcutaneous tissue by an infusion site. Humulog is a fast acting insulin beginning to lower blood sugar in 15 minutes and its effects last 6-8 hrs. The patient was also on Ambilify, and antipsychotic and Lexapro, and antidepressant/antianxiety medication. The physician assessed the patient at 8:47 PM. Chief complaint in physician notes include "suicide attempt." The time of ingestion (insulin) was identified as 8 PM. The ingestion was intentional and the amount of insulin was 'Unknown." The patient's psychiatric assessment by the physician identified the patient was depressed with suicidal thoughts and hopelessness. The Medical Screening Examination (MSE) included a Complete Blood Count, Complete Metabolic Profile and EKG. The potassium level was low at 3.2 (lab normal 3.5-5.0). Blood sugars performed in the ED were: 118 at 8:55 PM by fingerstick; 153 with lab draw at 9:25 PM and the last one done at 9:49 PM, a fingerstick with 152 blood sugar. EKG was normal. Aspirin and Tylenol blood levels were within normal limits. Record review of the psychiatric assessment performed by Licensed Mental Health Practitioner (LMHP) "J" at 10:49 PM revealed the patient stated "I just want to die" and that the patient "took too much insulin." The patient revealed that there had been a previous attempt to harm self the same way in the past. The patient lives with the mother. Suicide risk score was "High." The patient confirmed having suicidal thoughts, intent and had a specific plan to end their life by overdosing on insulin. Judgement was identified as 'Poor." The LMHP reported the findings to the Psychiatrist on call who wanted the patient transferred and admitted to an inpatient acute psychiatric hospital that treats adolescents. Record review of the form titled "Certificate of Transfer" dated 7/10/16 at 11:15 PM notes the patient was to be transferred by "POV" Privately Owned Vehicle. Vital signs at 11:00 PM before transfer were: BP 108/65; Pulse 70; Respirations 16 and Temperature 98.2 Fahrenheit. A blood sugar before transfer was not documented. Risks of transfer identified on the form include only "MVC" (motor vehicle collision) and benefits "definitive care." Under the section Patient condition the form has checked the box stating "There is not reasonable likelihood of deterioration from or during transport". The physician and the mother signed the transfer form. B. Interview with LMHP "J" on 9/27/16 at 10:35 AM confirmed Patient #12 was suicidal and had a plan using insulin. The The patient told the LMHP they "wanted to die".The patient reported using insulin in the past for a suicide attempt. LMHP discussed the assessment with the psychiatrist on call who felt the patient needed acute inpatient care and hospitalization . The LMHP stated the patient had an Emergency Medical Condition based on the fact that Patient 12 was "actively suicidal." The LMHP did not know how the patient used insulin, if by shot or insulin pump, or know if the pump was still in the patient's possession. C. Interview with Registered Nurse "G" on 9/27/16 at 5:00 PM. RN G confirmed being Patient 12's ED nurse on 7/10/16. The nurse was asked about the lack of documentation regarding the patient's insulin pump. The record does not contain what the settings were, infusion history evaluation or if the pump was still infusing into the patient. The nurse stated the patient "almost had to have had the pump on". The nurse thought the mom had shut it off before arrival. The nurse stated that the patient refused to talk to her or answer questions. The nursing information came from the mother. RN G confirmed a blood sugar was not done prior to transfer with the last one done at 9:49 PM. RN G confirmed the patient was suicidal and had an EMC requiring transfer. RN G recalled discussing with the Mother the method of transfer. The Mother related that the last time the patient went in the ambulance Patient 12 was uncooperative, taking off monitors and hitting staff. The nurse stated the Mother wanted to transport in her car. RN G stated the doctor makes the ultimate decision on the method to transfer. The nurse related that there is a place on the "Against Medical Advice" form that is used to document refusal of ambulance transfer. The nurse confirmed the record does not contain a refusal of ambulance transfer or any discussion with the patient regarding ambulance transfer. D. Interview with Medical Doctor (MD) "C" who is the ED Medical Director on 9/28/16 at 9:05 AM regarding the ED record from the 7/10/16 visit for Patient 12 revealed confirmation that the patient had an EMC related to a psychiatric condition. Regarding transfer with the patient's insulin pump the physician responded that can be "tricky." Insulin is necessary to maintain normal insulin levels. It can be lethal if you leave it on or lethal if you take it off. MD C stated that it is a judgement call regarding whether the patient can be safely transferred by the mother and it depends on if they can be reliable and reasonable it "may be ok." MD C stated that the physician determines the method of transfer and verbally discusses it with the nurse. The physician signature on the transfer form verifies that it is a safe method to transfer. E. Phone interview with MD "A" on 9/29/16 at 2:00 PM confirmed MD A was Patient 12's ED MD on 7/10/16. MD A related that he medically cleared the patient by doing repeat blood sugars to ensure they were not showing decline and that her laboratory results were negative. MD A determined the patient was stable for transfer to treat a psychiatric emergency. MD A did not know if the patient's insulin pump was infusing and with the patient or not. MD A reported a discussion with mom regarding transport to the psychiatric hospital by ambulance. The mom wanted to transport the patient as she felt an ambulance would cause increased stress. The mother did transport the patient by her private vehicle. MD A confirmed the discussion regarding transfer and refusal of transfer by ambulance was not documented in the record. F. Record review of the receiving hospital admission documentation reveals the patient was admitted on [DATE]. The attending psychiatrist documented the patient presented voluntary by guardian "after overdosed on her insulin pump and having to be taken to a hospital where she was medically cleared." The physician also noted that "upon her admission was taken off her insulin pump". The patient transferred by private vehicle with the insulin pump, method of suicide per patient, in their possession. G. Record review of the facility policy titled "EMTALA- Emergency Medical Treatment and Active Labor Act" effective date 2/1/16 identified a psychiatric patient with potential harm to self or others would always be considered an emergency medical condition to be screened and treated. The policy defines an "Appropriate Transfer" is a transfer in which the physician has certified the patient condition for transfer, the destination facility and physician have accepted the care of the patient, the patient, or responsible party has agreed to the transfer and the needed equipment, level of staff and mode of transport is available. The transfer is to be provided through qualified personnel and transportation equipment as required and as determined by the transferring physician. The section titled "Transfer by Private Vehicle": Patients being transferred for a hospital to hospital transfer who may be at risk of deterioration "shall be transferred by appropriate medical vehicle."; Patients requesting to utilize their private vehicle who are deemed capable of making such a decision by the responsible physician may do so upon meeting the documentation requirements for private vehicle transfer.; The requirements are discussion of risk/benefit and documentation of the risks discussed. The responsible persons understanding and capability of making an informed decision are to be documented.; The risks discussed will be inserted into the Ambulance Refusal Form in the section labeled "Risks." The Ambulance Refusal Form will be signed by the patient or responsible decision maker or if signature is refused that is to be noted on the form in the area provided for patient signature. The refusal form is to be signed by the physician or ED provider and witnessed on the form.; Where the physician or ED provider deems it appropriate they may further document the refusal and warnings provided through the use of an "Against Medical Advice" form. The record for Patient 12 does not include this documentation for transfer by private vehicle as required by facility policy.

Based on record review, review of the facility Emergency Treatment and Labor Act (EMTALA) policies, staff and provider interviews the facility failed to provide 1 (Patient 20) of 30 sampled patients an appropriate medical screening examination to evaluate/address the patient's extremely elevated blood pressure to ensure the patient did not have an Emergency Medical Condition (EMC); and failed to provide 1 (Patient 12) an appropriate safe transfer. Patient 12 who was actively suicidal was transported by private vehicle for direct admission to an inpatient psychiatric facility for stabilization and treatment of her EMC. The total sample size was 30. Findings are: A. Record review of Patient 12's medical record revealed the patient, a minor adolescent, was brought to the ED on 7/10/16 at 8:35 PM. The nursing documentation on arrival reveals the mother told the nurse the patient had been overdosing with an insulin pump. The patient is a diabetic and uses the insulin pump to infuse insulin through a subcutaneous site on a continual basis. The pump is programmed to deliver a continual rate of insulin and also a bolus or extra insulin to cover the consumption of carbohydrates to keep blood sugars in normal range. The American Diabetes Association defines target blood glucose (sugar) goals as 70-130 before meals and less that 180 after meals. The infusion of too much insulin can result in [DIAGNOSES REDACTED] (low blood glucose) that can result in a variety of symptoms ranging from clumsiness, trouble talking, confusion, loss of consciousness, seizures or death. The mother reported the patient had a history of suicidal intention. Humulog was identified as the insulin used by the patient. Humulog is used in insulin pumps to infuse insulin into the subcutaneous tissue by an infusion site. Humulog is a fast acting insulin beginning to lower blood sugar in 15 minutes and its effects last 6-8 hrs. The physician assessed the patient at 8:47 PM. Chief complaint in physician notes include "suicide attempt." The time of ingestion (insulin) was identified as 8 PM. The ingestion was intentional and the amount of insulin was 'Unknown." The patient's psychiatric assessment by the physician identified the patient was depressed with suicidal thoughts and hopelessness. Blood sugars performed in the ED were: 118 at 8:55 PM by fingerstick; 153 with lab draw at 9:25 PM and the last one done at 9:49 PM, a fingerstick with 152 blood sugar. Record review of the psychiatric assessment performed by Licensed Mental Health Practitioner (LMHP) "J" at 10:49 PM revealed the patient stated "I just want to die" and that the patient "took too much insulin." The patient revealed that there had been a previous attempt to harm self the same way in the past. The patient lives with the mother. Suicide risk score was "High." The patient confirmed having suicidal thoughts, intent and had a specific plan to end their life by overdosing on insulin. Judgement was identified as 'Poor." The LMHP reported the findings to the Psychiatrist on call who wanted the patient transferred and admitted to an inpatient acute psychiatric hospital that treats adolescents. Record review of the form titled "Certificate of Transfer" dated 7/10/16 at 11:15 PM notes the patient was to be transferred by "POV" Privately Owned Vehicle. Vital signs at 11:00 PM before transfer were: BP 108/65; Pulse 70; Respirations 16 and Temperature 98.2 Fahrenheit. A blood sugar before transfer was not documented. Risks of transfer identified on the form include only "MVC" (motor vehicle collision) and benefits "definitive care." Under the section Patient condition the form has checked the box stating "There is not reasonable likelihood of deterioration from or during transport". The physician and the mother signed the transfer form. Interview with LMHP "J" on 9/27/16 at 10:35 AM confirmed Patient #12 was suicidal and had a plan using insulin. The The patient told the LMHP they "wanted to die".The patient reported using insulin in the past for a suicide attempt. LMHP discussed the assessment with the psychiatrist on call who felt the patient needed acute inpatient care and hospitalization . The LMHP stated the patient had an Emergency Medical Condition based on the fact that Patient 12 was "actively suicidal." The LMHP did not know how the patient used insulin if by shot or insulin pump or know if the pump was still in the patient's possession. Interview with Registered Nurse "G" on 9/27/16 at 5:00 PM. RN G confirmed being Patient 12's ED nurse on 7/10/16. The nurse was asked about the lack of documentation regarding the patient's insulin pump. The record does not contain what the settings were, infusion history evaluation or if the pump was still infusing into the patient. The nurse stated the patient "almost had to have had the pump on". The nurse thought the mom had shut it off before arrival. The nurse stated that the patient refused to talk to her or answer questions. The nursing information came from the mother. RN G confirmed a blood sugar was not done prior to transfer with the last one done at 9:49 PM. RN G confirmed the patient was suicidal and had an EMC requiring transfer. RN G recalled discussing with the Mother the method of transfer. The Mother related that the last time the patient went in the ambulance he/she was uncooperative, taking off monitors and hitting staff. The nurse stated the mother wanted to transport in her car. RN G stated the doctor makes the ultimate decision on the method to transfer. The nurse related that there is a place on the Against Medical Advice form that is used to document refusal of ambulance transfer. The nurse confirmed the record does not contain a refusal of ambulance transfer or any discussion with the patient regarding ambulance transfer. Interview with Medical Doctor (MD) "C" who is the ED Medical Director on 9/28/16 at 9:05 AM regarding the ED record from the 7/10/16 visit for Patient 12 revealed confirmation that the patient had an EMC related to a psychiatric condition. Regarding transfer with the patient's insulin pump the physician responded that can be "tricky." Insulin is necessary to maintain normal insulin levels. It can be lethal if you leave it on or lethal if you take it off. MD C stated that it is a judgement call regarding whether the patient can be safely transferred by the mother and it depends on if they can be reliable and reasonable it "may be ok." MD C stated that the physician determines the method of transfer and verbally discusses it with the nurse. The physician signature on the transfer form verifies that it is a safe method to transfer. Phone interview with MD "A" on 9/29/16 at 2:00 PM confirmed MD A was Patient 12's ED MD on 7/10/16. MD A related that he medically cleared the patient by doing repeat blood sugars to ensure they were not showing decline and that her laboratory results were negative. MD A determined the patient was stable for transfer to treat psychiatric emergency. MD A did not know if the patient's insulin pump was infusing and with the patient or not. MD A reported a discussion with mom regarding transport to the psychiatric hospital by ambulance. The mom wanted to transport the patient as she felt an ambulance would cause increased stress. The mother did transport the patient by private vehicle. MD A confirmed the discussion regarding transfer and refusal of transfer by ambulance was not documented in the record. Record review of the receiving hospital admission documentation reveals the patient was admitted on [DATE]. The attending psychiatrist documented the patient presented voluntary by guardian "after overdosed on her insulin pump and having to be taken to a hospital where she was medically cleared." The physician also noted that "upon her admission was taken off her insulin pump". The patient transferred by private vehicle with the insulin pump, method of suicide per patient, in their possession. Record review of the facility policy titled "EMTALA- Emergency Medical Treatment and Active Labor Act" effective date 2/1/16 identified a psychiatric patient with potential harm to self or others would always be considered an emergency medical condition to be screened and treated. The policy defines an "Appropriate Transfer" is a transfer in which the physician has certified the patient condition for transfer, the destination facility and physician have accepted the care of the patient, the patient, or responsible party has agreed to the transfer and the needed equipment, level of staff and mode of transport is available. The transfer is to be provided through qualified personnel and transportation equipment as required and as determined by the transferring physician. The section titled "Transfer by Private Vehicle": Patients being transferred for a hospital to hospital transfer who may be at risk of deterioration "shall be transferred by appropriate medical vehicle."; Patients requesting to utilize their private vehicle who are deemed capable of making such a decision by the responsible physician may do so upon meeting the documentation requirements for private vehicle transfer.; The requirements are discussion of risk/benefit and documentation of the risks discussed. The responsible persons understanding and capability of making an informed decision are to be documented.; The risks discussed will be inserted into the Ambulance Refusal Form in the section labeled "Risks." The Ambulance Refusal Form will be signed by the patient or responsible decision maker or if signature is refused that is to be noted on the form in the area provided for patient signature. The refusal form is to be signed by the physician or ED provider and witnessed on the form.; Where the physician or ED provider deems it appropriate they may further document the refusal and warnings provided through the use of an "Against Medical Advice" form. The record for Patient 12 does not include this documentation for transfer by private vehicle as required by facility policy. B. Medical Record Review of the ED visit on 6/14/16 for Patient 20 revealed the patient came to the ED at 9:18 AM. The Triage Notes identified that the patient reported "thoughts of paranoia, and feeling disconnected with thoughts of suicide with no plan." Initial vital signs were: BP 187/119, Temperature (T) 98.2 oral, Pulse (P) 106, Respirations (R) 24 and oxygen saturation 96% on room air, and currently takes no medications. The record identified Patient 20's past medical history of [DIAGNOSES REDACTED] The MSE (Medical Screening Exam) was completed by the Doctor of Osteopathic Medicine (DO)-B. The exam noted that Patient 20 presented with a chief complaint of psychiatric problems. The onset was one week prior to arrival. The patient denied any hallucinations, had unclear thinking, denied suicidal or homicidal thoughts. The patient is not uncooperative. The review of symptoms included: Respiratory: lungs clear and breath sounds were equal bilaterally, CV (Cardiovascular): Tachycardia (fast heart beat), the rhythm was regular. Neurological: oriented to person, place and time. The patient was awake and alert, memory was intact. Psychiatric: no visual or auditory hallucinations. The orders included: Blood Alcohol, CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), Lipid Panel, Protime/INR, TSH (Thyroid Stimulating Hormone), UA and UA for drug screen (unable to void before discharge), Hgb A1C, BP monitor per protocol, Mental health consult per protocol and Suicidal precautions per protocol. IMPRESSION: PSYCHOSIS (a lack of understanding with reality). DO-B documented "The patient was discharged to Home. The patient's condition upon discharge was good. Education was provided to the patient in reference to the impressions, diagnostic study results, treatment, prognosis and need for follow up. Instructions given to the patient: Psychosis. Follow up: As recommended by psych." DO-B's documentation lacked mention of the elevated blood pressures. The evaluation for Mental Health was completed by LMHP (Licensed Mental Health Practitioner)-I on 6/14/16 at 10:45 AM. Patient 20 was identified as denying suicidal thoughts or thoughts of hurting others, denied hallucinations, does experience paranoia related to minorities and homosexuals, and delusions "Gotta be alive in 2029 for the asteroids." Is homeless and resides in (gender) car, travels the United States, is on disability and has a medical history of [DIAGNOSES REDACTED]. An evaluation by the Psychiatrist/LMHP and in coordination with the ED doctor is completed to determine if an Emergency Medical Condition (EMC) for Mental Health exists. For Patient 20, it was felt that Patient 20 did not have an EMC for Mental Health and it was recommended to follow up with out patient psychiatric referrals (address and phone number provided) upon dismissal. Review of Patient 20's "Tabular Trend" form with BP's and Pulses recorded while in the ED revealed: 09:17 AM- BP 187/119, P 106 09:20 AM- BP 214/153, P 100 09:21 AM- BP 228/145, P 102 09:30 AM- BP 221/145, P 101 09:40 AM- BP 202/141, P 97 09:50 AM- BP 202/123, P 85 09:52 AM- BP 205/125, P 87 10:00 AM- BP 206/159, P 96 10:20 AM- BP 196/138, P 92 An interview with Registered Nurse (RN) H on 9/27/16 at 11:35 AM confirmed being the nurse caring the for Patient 20 during the 6/14/16 ED visit. Upon request of reviewing the documented BP's on Patient 20's record, RN H verified that the record lacked documentation of physician notification of the elevated BP's and lacked any dismissal instructions regarding following up about the BP's or printed information given about elevated BP's. RN H stated, "I usually chart if there is a high BP that I notified the doctor before they are discharged . But I don't see it anywhere in here." RN H verified that no medications were administered to Patient 20 during the ED visit. When RN H was asked if (gender) felt that it appeared Patient 20 had a hypertensive EMC? RN H stated, "Yeah" When asked if (gender) felt that Patient 20 was safe to send home when discharged , RN H stated, "No, I don't see it on the health history or a history of high BP." Do you feel Patient 20 then had an EMC at the time of Discharge? RN H stated, "Yes, due to the high blood pressure and without being on meds or a history." An interview with The Medical Director of ED (MD)-C on 9/28/16 at 9:05 AM regarding Patient 20, (due to DO-B is no longer employed at the facility and not available for interview) revealed the opportunity to review the 6/14/16 record. When asked if MD-C felt Patient 20 had an EMC for Mental Health, MD-C stated "No." When asked about the elevated BP's ranging from 187/119-214/153 during the ED visit if MD-C felt that Patient 20 had an EMC Medically related to the BP's, MD-C stated, "No." MD-C stated, "With (gender) labs (essentially normal), no chest pain, no shortness of breath and (gender) renal function was fine, the patient can follow up as an outpatient. According to the ACEP (American College of Emergency Physicians) it says if the patient is asymptomatic they can follow up as an outpatient. So on discharge give the outpatient information for blood pressure and outpatient information." MD-C verified that the discharge instructions lacked paperwork about blood pressure and there was not a follow up for the blood pressure issues mentioned. "I do see the discharge instructions say to follow up with psychiatric treatment." An address and phone number was listed for that on the discharge paperwork. When asked if MD-C felt that Patient 20 had a Medical EMC related to the elevated blood pressures at discharge, MD-C stated, "No, (gender) was asymptomatic and per ACEP (Patient 20) could follow up as an outpatient. However the discharge instructions should have had follow up referral information about the blood pressure on it." Record review of the facility policy titled "EMTALA" effective 2/1/2016 identified under title "A medical screening examinations is provided to any person presenting themselves anywhere on the campus who is seeking emergency services to determine whether that person has an emergency medical condition. An Emergency Medical Condition is defined in the policy as "As defined by law is a condition manifesting itself with acute symptoms of [DIAGNOSES REDACTED]. Emergency medical conditions always include women in labor, patients with substance abuse or current intoxication, patients with severe pain, and psychiatric patients that might or could ultimately be at risk to self or others." Review of the ACEP website -Current Clinical Policies Management- Asymptomatic Elevated Blood Pressure Volume 62 No 1 dated July 2013 revealed: -In patients with asymptomatic markedly elevated blood pressure, does ED medical intervention reduce rates of adverse outcomes? For patient management recommendations, Level A and Level B recommendatins- none specified; Level C recommendation was: (1) In patients with asymptomatic markedly elevated blood pressure, routine ED Medical intervention is not required. (2) IN SELECT PATIENT POPULATIONS (EG. POOR FOLLOW-UP), EMERGENCY PHYSICIANS MAY TREAT MARKEDLY ELEVATED BLOOD PRESSURE IN THE ED AND/OR INITIATE THERAPY FOR LONG-TERM CONTROL. [CONSENSUS REMMENDATION] (3) PATIENTS WITH ASYMPTOMATIC MARKEDLY ELEVATED BLOOD PRESSURE SHOULD BE REFERRED FOR OUTPATIENT FOLLOW-UP. [CONSENSUS RECOMMENDATION] Patient 20 is homeless and lives in (gender) car and travels the United States. Review of the Mayo Clinic website- High Blood Pressure article dated 9/9/2016 revealed the following categories to classify blood pressure: -Normal blood pressure- when the blood pressure is normal if below 120/80 mmHg (millimeters of mercury) -Prehypertension- Prehypertension is a systolic (top number-measures your arteries when your hear beats) pressure ranging from 120-139 mmHg or a diastolic (lower number-measures the pressure in your arteries between beats). -Stage 1 hypertension- Stage 1 hypertension is a systolic pressure ranging from 140-159 mmHG or a diastolic pressure ranging from 90-99 mmHg. -Stage 2 hypertension- More severe hypertension, stage 2 hypertension is a systolic pressure of 160 mmHG or higher or a diastolic pressure of 100 mmHg or higher. Uncontrolled high blood pressure can lead to: heart attack or stroke, aneurysm, heart failure, weakened and narrowed blood vessels in the kidneys, thinkened, narrowed or torn blood vessels of the eyes, metaboli[DIAGNOSES REDACTED], trouble with memory or understanding.