CMS-TriStar-Skyline-Medical-Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) were not discouraged from seeking a Medical Screening Examination (MSE) by asking for payment prior to performing a MSE for 1 of 20 (Patient #20) sampled patients.

The findings included:

1. The hospital policy EMTALA (Emergency Medical Treatment and Labor Act) Tennessee Medical Screening Examination and Stabilization Policy revealed, ...An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and...1. the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition...The hospital must perform an MSE to determine if an EMC [Emergency Medical Condition] exists...Triage is not equivalent to an MSE...An MSE is the process required to reach, with reasonable clinical confidence, the point which it can be determined whether the individual has an EMC or not. It is not an isolated event...An MSE...will not be delayed to inquire about the individual's method of payment or insurance status, or conditioned on an individual's completion of financial responsibility form...or payment of a co-payment for any services rendered...

2. Medical record revealed Patient #20 arrived at ED #1 on 9/6/2020 at 7:57 PM via walk-in with the stated complaint of Chest Pain since last night. He had one insurance plan listed on the demographic sheet and the Patient Employer was listed as DISABLED PATIENT.

The Rapid Initial Assessment on 9/6/2020 at 8:00 PM, revealed Patient #20 stated the chest pain feels like someone is sitting on my chest. The pain intensity score was rated moderate-6.

A WAIVER OF RIGHT TO MEDICAL SCREENING EXAMINATION was signed by Patient #20 and witnessed by Nurse #1 on 9/6/2020 at 8:10 PM.

The Disposition Comments on 9/7/2020 at 8:11 PM, revealed ...PT LPMSE [left prior to MSE] STATING THIS IS A BUNCH OF BULLSHIT, YALL HAVE SCREWED MY INSURANCE UP AND I'M NOT PAYING A CO PAY AMBULATED FROM ED IN NAD [no apparent distress]...

The ambulance run report dated 9/6/2020 revealed Emergency Medical Services (EMS) received a call at 9:37 PM to respond to the home of Patient #20. When EMS arrived at 9:42 PM, Patient #20 informed EMS he had the chest pain on and off for a couple of days with no relief and described the pain as pressure to the left side of his chest. He was transported hospital #2 non-emergency traffic and was monitored during transported. No interventions were needed.

Medical record review revealed Patient #20 arrived at ED #2 on 9/6/2020 at 10:34 PM, with the Chief Complaint of Chest Pain.

The ED #2 History and Physical revealed, ...Chest pain worse with activity times past 48 hours. Strong family history of heart disease. Work-up thus far is negative. However he does have several risk factors given his underlying [DIAGNOSES REDACTED], diabetes, hypertension, tobacco abuse, and obesity. Will admit to MedSurg observation with telemetry...

The Discharge Summary dated 9/7/2020 revealed, ...Cardiac markers and electrocardiogram did not show signs of acute cardiac injury or ischemia. Chest pain has resolved. He is felt to be medically suitable to discharge...consideration of further cardiac evaluation ...begin taking daily aspirin...given prescription for sublingual nitroglycerin...

3. In an interview in the conference room on 9/15/20 at 9:15 AM, the Chief Medical Officer (CMO) stated Patient #20 was taken into registration and was asked by the Registrar for a $90.00 co-pay. The CMO stated he believed the Registrar thought the MSE had been completed. The CMO stated the Registrar asked inappropriately for a co-pay prior to a MSE being performed.

In an interview in the conference room on 9/15/20 at 10:16 AM, the Patient Access Director (Supervisor for Registration) stated Patient #20 was brought to registration, but the nurse (Nurse #2) did not disclose the MSE had not been performed. The Patient Access Director stated she believed the Registrar assumed the MSE had been completed.

In an interview in the conference room on 9/15/20 at 10:38 AM, the ED Nurse Manager stated she conducted an investigation into the incident with Patient #20 and confirmed the Registrar inappropriately asked for the copay prior to the MSE being performed.

In a telephone interview on 9/15/2020 at 12:07 PM, the Registrar was asked about Patient #20. She stated he had one insurance card with him and when she looked up his information, he had a $90.00 co-pay. When she told the patient, he called his mother and told the Registrar he should not have a co-pay and asked to leave. When asked at what point can she asked for a co-pay, the Registrar stated, Can ask for co-pay even if they haven't had an MSE. Don't have to wait until they've seen a physician until you ask for a co-pay.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, facility documents, medical record review and interview, the hospital failed to ensure care was provided in a safe setting when no psychiatric medication reconciliation was completed within 24 hours that resulted in an adverse reaction (increased tremors) due to not receiving a long term home medication for 1 of 3 (Patient #1) sampled patients reviewed.

The findings included:

1. Review of the manufacturer data sheet for Ativan retrieved from www.accessdata.fda.gov documented, ...Abrupt discontinuation of product should be avoided... Abrupt termination of treatment may be accompanied by withdrawal symptoms. Symptoms reported following discontinuation of benzodiazepines include... irritability... derealization... numbness/tingling of extremities... tremor... agitation... short term memory loss...

2. Review of the hospital's medication reconciliation policy revealed, ...A list of the patient's current medications will be obtained upon admission...The medications will be documented/entered into Meditech in the Admit History Intervention, psych admission Part B, under medication history, within 24 hours of admission...the Medication Reconciliation Order form must be updated with any identified discrepancies [any inconsistency or difference in the medication regimen noted during the reconciliation] within 24 hours of admission...

3. Medical record review revealed Patient #1 was admitted on [DATE] with a diagnosis of Major neurocognitive disorder with behavior disturbance. Additional medical history revealed Coronary Artery Disease, Hypertension, High Cholesterol, and had a pacemaker.

Review of a history and physical dated 10/4/18 at 7:00 PM, the Psychiatrist documented, ...Assessment & [and] Plan...currently involuntarily due to psychosis and hallucinations...Plan...She will have medication reconciliation...Electronically signed by [Named Psychiatrist] on 10/5/18 at 1300 [1:00 PM]...

The hospital was unable to provide documentation to confirm a psychiatric medication reconciliation was completed by the Psychiatrist.

Review of the Medication Administration Record (MAR) revealed that Patient #1 did not receive Ativan (Lorazepam) from 10/4/18 to 10/6/18.

Review of the clinical documentation record dated 10/6/18 at 10:18 AM documented, ...REPORTS TREMORS MORE SEVERE TODAY: PHYSICIAN MADE AWARE, FAMILY REPORTS WORSE THAN THEY HAVE EVER SAW TODAY...

Review of a physician's order dated 10/6/18 at 11:02 AM, revealed Ativan (Lorazepam) 1mg. IM (intramuscularly) ONCE. Review of the MAR revealed Patient #1 did receive 1 miligram (mg) IM one time on 10/6/18.

Review of a physician's order dated 10/6/18 at 11:02 AM, revealed Ativan (Lorazepam) 0.5 mg po (by mouth) three times per day. Review of the MAR revealed Patient #1 did receive Ativan 0.5mg three times per day from 10/7/18 until discharge.

Review of the clinical documentation record dated 10/6/18 at 3:15 PM, documented, ...Reassessment comments: Patient is alert, oriented to self only...Family here and reported patient is worse than they have ever seen. Patient with tremors to hands face unable to hold water glass. has difficulty drinking water due to shakes. (Named Psychiatrist) aware. Patient daughter and charge nurse discussed medications. Patient had been taking Ativan prior to admission. Ativan IM 1 mg given this morning per doctor order. Ativan scheduled and administered as ordered. shakiness slightly improved in the afternoon but patient continues to have difficulty holding her glass...unable to ambulate today due to shakiness...

Review of the clinical documentation record dated 10/6/18 at 7:30 PM documented, ...TREMORS APPARENT BUT THEY SEEM TO HAVE REDUCED IN SEVERITY SINCE THE NIGHT BEFORE...

Review of the clinical documentation record dated 10/7/18 at 10:20 AM documented, ...tremors: None...

Review of the clinical documentation record dated 10/7/18 at 7:30 PM documented, ...tremors: Present/Exists...

Review of the clinical documentation record dated 10/8/18 at 4:01 AM documented, ...10/7 PM...TREMORS HAVE REDUCED SINCE LAST NIGHT...

Review of the clinical documentation record dated 10/8/18 at 10:06 AM documented, ...tremors: None...

Review of the clinical documentation record dated 10/8/18 at 2:26 PM documented, ...Reassessment comments: 10/8/18-days...Requires assist with meals today due to tremors, however they are greatly improved to the hands from few days ago...

Review of the clinical documentation record dated 10/8/18 at 7:30 PM documented, ...tremors: None...

During an interview with the Physician Assistant on 2/20/19 at 10:32 AM, He stated that the standard is not to prescribe psychiatric medications. We would not start it (Ativan). He further stated that she had gout and cardiac arrhythmias. He stated that both medical and psych are to see the patient within 24 hours. He stated that the Psychiatrist was responsible to reconcile psychiatric medications.

During an interview on 2/19/19 at 1:03 PM, in the conference room, the Chief Quality and Patient Safety Officer (CQPSO) verified that Patient #1's home medications were not reconciled by a Psychiatrist. She further stated that the Psychiatrist is no longer employed at this hospital. The Psychiatrist voluntarily relinquished her privileges and moved out of state. She was unaware of how to get in touch with the Psychiatrist as her whereabouts were unknown.

During a telephone interview on 2/22/19 at 9:45 AM, with Patient #1's daughter (Power of Attorney POA) revealed the POA took Patient #1 to a regional hospital because she was becoming increasingly anxious and confused. Once the patient got to this hospital, the daughter tried to call and check on her but they would not tell me anything because I did not have a code. Finally the daughter was able to talk to a nurse and asked if they had a list of the patient's medications. The daughter told the nurse the patient had her medications with her and to make sure she takes her Lorazepam 3 times a day. The nurse then told the patient's daughter could see the patient on Saturday at noon - that was the visitation time. When the patient's daughter saw her mother that Saturday, and the staff wheeled her in sitting in a wheelchair, the patient's daughter thought the patient was having seizures. The patient's daughter asked the nurse if the patient was getting her Lorazepam, and she went and got the chart. The next thing the daughter knew the nurse was bringing the patient an injection of Lorazepam. Patient #1's daughter stated her mother did not even know her sister when she got there. Patient #1's daughter stated Patient #1 spoke gibberish. She was coherent when her daughter left her at the 1st hospital. The patient did not receive any Lorazepam until Saturday when the family came to see her. They did not check the medications she was on at home.

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Based on facility documents, observation and interview, the hospital failed to maintain a sanitary dietary department, failed to ensure the dietary staff followed established policies and procedures for hand hygiene, food preparation, equipment cleaning, and failed to ensure minimum dishwashing temperatures during 2 of 2 observations (3/4/19 and 3/5/19) of the kitchen.

The findings included:

1. Review of the hospital's Safety and Sanitation Checklist revealed that all personnel are to follow proper hand washing procedures.

2. Review of the hospital's welcome packet to the food and nutrition department revealed to leave cell phones in the employees locker or car and it is the expectation that the phones are not used while on duty. The packet further revealed that an employee with poor hygiene can contaminate the food, and proper handwashing techniques were detailed such as disposable gloves should be worn over thoroughly washed hands only.

3. Review of the hospital's food service hand hygiene policy revealed hands are washed with soap and water at the following times: Before handling clean utensils or equipment, before putting on gloves, after removing gloves, between handling raw and cooked foods, and after touching clothing.

4. Review of the hospital's food service infection control practices revealed kitchen staff are not to perform multiple activities while wearing gloves which will be used in food handling.

5. Observations on 3/4/19 beginning at 10:20 AM, in the kitchen revealed Cook #1 was checking temperatures during the cooking of chicken breasts without washing his hands or donning gloves. After he checked the temperature, he picked up a set of tongs and began moving the pieces of chicken around. He then laid the tongs on a cart and walked around to the stove. He donned gloves, but did not wash his hands prior to donning the gloves and began to check on the food cooking on the stove. Cook #1 then put his right gloved hand in his pocket. Cook #1 in the same gloves then picked-up a spray can and sprayed a clean pan. He then picked up a cardboard box with a blue plastic bag inside it and picked-up the box and poured rice into a large long shallow pan with the same gloves on. He then removed his gloves and washed his hands but did not dry his hands. With wet hands, he took a large long handled pot to a cooking sink and filled it with water and poured it over the rice. He covered the pan with aluminum foil and put the pan in the oven. He then donned gloves without washing his hands.

During an interview on 3/5/19 beginning at 1:40 PM, in the Quality conference room with the Director of Food and Nutrition Services (DFNS), who is also a Registered Dietitian stated it was not acceptable to put his hand in his pocket and not perform hand hygiene after taking it out of the pocket. She stated the remainder of the above activities were acceptable as long as he was not touching ready to eat food. She stated that she would not expect him to wash his hands prior to donning gloves because wet hands are hard to don gloves.

6. Observations on 3/4/19 beginning at 10:20 AM, in the kitchen revealed Cook #2 was at the stove and picked up a pot of gumbo with no gloves on and poured the gumbo into a long shallow pan, picked up the pan and walked out to the retail area and put the pan of gumbo out. Cook #2 did not wash his hands but when entering back into the kitchen, Cook #1 asked him to check on the chicken. Cook #2 picked up the thermometer without washing his hands or donning gloves and wiped the thermometer off with a sanitizing pad and began to check the chicken temperatures. Cook #2 then put the cooked chicken into a pan and carried the pan of chicken across the kitchen to the stove with no gloves on. He then picked up a large spoon and began to drizzle a gravy like substance over the cooked chicken breasts and took the pan out to the retail area. Cook #2 came back into the kitchen and went into the walk in refrigerator, and pushed a cart out with chicken breasts in a large bowl. He did not wash his hands but donned gloves and picked up the chicken breasts with his gloved hands and laid them in the large tilt pan.

During an interview on 3/5/19 beginning at 1:40 PM, in the Quality conference room with the DFNS, she stated all of the above activities were acceptable regarding Cook #2 because he did not touch food with his bare hands. She further stated that she had been employed about 1.5 years. She stated the prior company's policys and procedures are what they were using. During a review of the policies she submitted, the DFNS stated they were the old company's policies and she will be getting the hospital's current food service policies. She stated she was told about 1.5 months ago that she now has the ability to tweak the hospital's current policies. She stated that she will be deleting the procedure to wash hands before and after donning gloves.

7. Observations on 3/4/19 beginning at 12:30 PM, during a kitchen tour with the Executive Chef revealed the following:

a. Patient Service Representative (PSR) #1 laid 2 cell phones on the counter in the food preparation area. The Executive Chef stated the phones should be in their pocket.

b. Two drip pans under the range top of the patient stove had a heavy accumulation of blackened greasy debris on top of the foil liner. Further observation revealed an accumulation of blackened sticky debris under the foil liner. Cook #1 stated they should be cleaned every night. The Executive Chef stated there is a cleaning schedule for all equipment.

c. The high temperature dishwashing machine had a wash temperature of 144 degrees Fahrenheit. The Executive Chef stated he would call service on that, but the final rinse is what really counts to sanitize the dishes.

8. Review of the dishwasher troubleshooting guide revealed symptoms related to ware not clean with possible causes to include incorrect water temperature and spotting of ware with possible causes to include Incorrect final rinse water temperature (minimum 180 F).

Review of the minimum temperature requirements permanently displayed on the dishwasher revealed the wash temperature should be a minimum of 150 degrees Fahrenheit.

Observations on 3/5/19 at 11:04 AM, in the kitchen, the wash temperature was 148 degrees Fahrenheit. The DFNS stated that the final rinse was what was important.

During an interview on 3/5/19 beginning at 1:40 PM, in the Quality conference room, the DFNS was asked about the wash temperature being less than 150 degrees for 2 of 2 observations. She stated that there is no manufacturer information that addresses that. She stated that it was always the final rinse temperature that was important and that sanitizes the dishes.

During a telephone interview on 3/5/19 at 2:06 PM, the manufacturer's local service manager was asked what the wash temperature should be. He stated, It should not be less than 150 F...you need to see 150 or above, that gets the soils off the ware... He was asked what should occur if the temperatures were 144 and 148. He stated, Place a service call, see if the O rings are in place...less than 150 will not get the dishes as clean...

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Based on facility documents, observation and interview, the hospital failed to ensure food products were stored under appropriate sanitary conditions.

The findings included:

Review of the hospital's Safety and Sanitation Checklist revealed that refrigerators and freezers are clean and the floors are free of food spoilage or build-up. All refrigerator and freezer items are to be covered, dated and labeled.

Review of the hospital's dating procedure for shelf life of foods revealed ready to eat foods shall be marked to indicate the date by which the food must be consumed.

Observations on 3/4/19 beginning at 12:30 PM, during a kitchen tour with the Executive Chef revealed the following:

a. A personal bottle of water was found in the prep freezer. The Executive Chef stated that the bottle of water is not a brand they use, and it shouldn't be in the freezer.

b. The floor area in the large freezer under the racks around the interior perimeter of the refrigerator had an accumulation of paper, tape, dirt, dust and an unsecured rusty support beam on the freezer floor. The Executive Chef stated that it should not look like that and it will be cleaned up.

c. A pan in the meat refrigerator (meat box) containing cooked macaroni and cheese had a plastic wrap cover that was not secured to the pan on one corner, therefore exposing the contents to potential contamination. There was no date/label on the macaroni and cheese. The Executive Chef stated it looked like someone tore open the corner and took a serving out and did not recover it. The Executive Chef confirmed there was no date on the macaroni and cheese.

d. A used disposable glove was lying on the floor of the dessert freezer floor. The Executive Chef reached and picked it up and put it in a trash receptacle.

e. There was an approximately 4-5 icicle hanging from a pipe in the ceiling of the dessert freezer. Directly under the icicle there was an approximately 1.5 inch frozen patch of ice that had dripped onto an open cardboard box with frozen bagged croissants visible. The Executive Chef stated that was new to him, he had not seen it before now and he would put in a call to get it repaired.

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During an EMTALA investigation of complaint # completed 12/11/17 to 1/8/18, Tristar Skyline Medical Center was found to be out of compliance with Requirements for the Responsibilities of Medicare Participating Hospitals in Emergency Cases 42 CFR PART 489.20 and 489.24. Based on review of facility policies, review of Medical Staff Bylaws, review of Medical Staff Rules and Regulations, review of Psychiatric On Call Schedules, medical record review, review of Behavioral Unit census records and interview, the facility failed to:

1. Ensure on-call psychiatrists who were available and on-call for duty performed an adequate examination and provided necessary treatment and/or services for all patients who presented to the Emergency Department (ED) with psychiatric signs/symptoms for 30 of 32 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) patient records reviewed who had presented to the ED seeking treatment.

2. Provide patients who presented to the Emergency Department (ED) with an appropriate Medical Screening Examination (MSE) within the capabilities of the hospital's emergency department and ensure patients presenting with psychiatric disorders were assessed by the hospital's on-call psychiatrists in order to determine if an emergency psychiatric condition existed for 30 of 32 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) patient records reviewed who had presented to the ED seeking treatment.

3. Ensure on-call psychiatrists performed an adequate assessment to determine the necessary treatment to stabilize signs/symptoms of psychiatric conditions for 30 of 32 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) patient records reviewed who had presented to the ED seeking treatment.

4. Ensure patients with identified emergency psychiatric conditions were transferred to Hospital A's inpatient psychiatric unit which had the capacity and capability to treat the patient. The hospital failed to minimize the risks to the patient's health by allowing patients with psychiatric conditions to remain in the hospital's ED for extended periods of time without stabilizing treatment while waiting to be transferred to an outside hospital. The failure of the hospital to admit and treat psychiatric patients resulted in an inappropriate transfer for 26 of 32 (#1, #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #24, #25, #26, #27 and #28) patients who had presented to the ED seeking treatment.

Refer to A-2404, A-2406, A-2407 and A-2409.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies, Medical Staff Bylaws, Medical Staff Rules and Regulations, Medical Staff On-Call Schedules, medical record review and interview, the facility failed to ensure on-call psychiatrists who were available and on-call for duty performed an adequate examination and provided necessary treatment and/or services for all patients who presented to the Emergency Department (ED) with psychiatric signs/symptoms for 30 of 32 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) patient records reviewed who had presented to the ED seeking treatment.

The findings included:

1. Review of the facilty's EMTALA [Emergency Medical Treatment and Labor Act] Tennessee Medical Screening Examination and Stabilization Policy revealed, ...To establish guidelines for providing appropriate medical screening examinations (MSE) and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA...An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED)...The MSE must be completed by an individual...qualified to perform such an examination to determine whether an EMC [emergency medical condition) exists...If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity of the facility, or an appropriate transfer as defined by and required by EMTALA. Stabilizing treatment shall be applied in a non-discriminatory manner...no different level of care because of ...payment source or ability, or any other basis prohibited by federal, state or local law...

Review of the facility's EMTALA Transfer Policy revealed, ...To establish guidelines for...providing an appropriate transfer to another facility of an individual with an emergency medical condition (EMC), who requests or requires a transfer for further medical care and follow-up to a receiving facility...Transfer of Individuals Who Have Not Been Stabilized...If an individual who has come to the emergency department has an EMC that has not been stabilized, the hospital may transfer the individual only if the transfer is an appropriate transfer...Higher Level of Care...A receiving hospital with specialized capabilities or facilities that are not at the transferring hospital (including...behavioral health units...) must accept an appropriate transfer of an individual with an EMC who requires specialized capabilities or facilities if the hospital has the capacity to treat the individual...

2. Review of the facility's MEDICAL STAFF BYLAWS reviewed 7/19/16 revealed, ...The Medical Staff shall provide services as applicable, to patients admitted or otherwise treated at [Hospital A] which includes the [Hospital A's psychiatric campus]...To provide patients with the quality of care that is commensurate with acceptable standards and available community services...To monitor and enforce compliance with these Bylaws, Rules and Regulations and hospital policies...

3. Review of the facility's MEDICAL STAFF RULES AND REGULATIONS reviewed 7/19/16 revealed, ...EMERGENCY SERVICES...All persons seeking emergency services and care will receive a medical screening examination and evaluation by a physician or a qualified medical person as designated by hospital policy...If the physician on call is requested by the emergency department physician to see an unassigned patient who has presented to the emergency department for treatment or evaluation, the on call physician must respond, regardless of the patient's ability to pay for any service...Patients with conditions whose definitive care is beyond the capabilities of the Hospital shall be referred to the appropriate facility, when in the judgment of the attending Physician the patient's condition permits such a transfer. Patient transfers shall be in accordance with EMTALA regulations...

4. Review of the facility on-call schedule revealed a psychiatrist was on call 24 hours a day 7 days a week during the time each of the 30 of 32 patients were in the ED.

5. Medical record review revealed Patient #1 presented to the Emergency Department (ED) at Hospital A on 10/21/17 at 7:31 AM for complaint of ...Aggressive behavior, Hallucinations, auditory, schizophrenia... Patient #1 had out of state Medicaid insurance.

Review of Physician Assistant #1's note dated 10/21/17 at 7:58 AM revealed Physician Assistant #1 initiated a Medical Screening Examination (MSE) which included: a History of Present Illness (HPI), a Risk of Psychiatric Illness, a Review of Systems (ROS), a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, ...He [Patient #1] is evasive with questions, but upon further discussions with family, they state that he has been having difficulties with voices, commands, and auditory hallucinations. He has been more aggressive recently and is hard to control at home. They attempted to take him to [Hospital A's psychiatric campus], but was instructed to come to the emergency department for medical clearance... Further review of Physician Assistant #1's note dated 10/21/17 at 4:05 PM revealed, ...Patient is having acute psychosis, with auditory hallucinations. Patient needs completion of psychiatric monitoring and treatment to ensure stabilization...Primary Impression: Acute psychosis ...Secondary Impressions: Auditory hallucinations, Schizophrenia...

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #1 on 10/21/17 at 8:00 AM which documented, ...I certify that this person is subject to involuntary care and treatment...Hx [history] of schizophrenia...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Acute psychosis with auditory hallucinations...Treatment may reduce symptoms...Patient needs safe place for treatment...

A nurse's note dated 10/21/17 at 8:25 AM documented, ...FAMILY IS CONCERNED FOR HIS INCREASE IN AGITATION, DECREASED SLEEP. STATES HE STAYS UP LATE PACING AROUND AND TALKS TO 'THE VOICES.' HIS MOM STATES HE HAS BEEN AGITATED ALTELY [lately] AND HAS BEEN KNOWN TO ATTACK OBJECTS. STATES HIS AUDITORY HALLUCINATIONS SEEM TO GET WORSE WHEN HE IS ANGRY. I NOTED THIS WHEN I TOLD HIM THIS IS A NO SMOKING CAMPUS. HE BECAME IRRITATED AND HIS SPEECH BECAME FASTER AND HE SPOKE VERY ANGRILY WITH NONPERSONS WHEN I LEFT TO GET HIM A NICOTINE PATCH. HE REFUSED THE NICOTINE PATCH, STATING HE 'SWALLOWED A GUN' AND DOESN'T WANT TO TAKE ANY NICOTINE INTO HIS BODY...

Review of the Emergency Medical Condition (EMC) Identified transfer form signed by a physician (illegible signature) revealed, ...Obtain level of care/service unavailable at this facility. Service: Psych [psychiatry]...Receiving Facility...[Hospital B]...Time of Transfer: 1650 [4:50 PM]...Date: 10/23/17...

There was no documentation the on-call psychiatrist had performed an assessment of Patient #1 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 57 hours and 19 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

6. Medical record review revealed Patient #2 (MDS) dated [DATE] at 9:22 PM for complaint of ...Depressed, Suicidal ideation... Patient #2 had out of state Medicaid insurance.

ED Physician #2's note dated 9/16/17 at 9:48 PM documented ED Physician #2 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, ...[Patient #2] brought to emergency department by EMS [emergency medical services] for bizarre behavior, depression and suicidal ideation. Unfortunately the patient is very accelerated, tangential with loose associations and it's very difficult to get a clear history from him. He does state he is suicidal and hopes to kill himself. He is name [has named] several options including lighting himself on fire, stabbing himself, running out in front of traffic, jumping off a building or drowning himself. He has made mention of his girlfriend leaving him and taking his dog but also has mentioned larger social issues such as the government, the military and the devil is being a cause for his frustrations...Focused PE [physical exam]...General/Const [Constitution]...odor of alcohol noted, disheveled with poor hygiene...Psychiatric...Abnormal Mood/Affect...Flight of ideas, Inappropriate, Irritable, Pressured Speech ...Abnormal Thinking/Perception...Suicidal with plan, Judgment abnormal... Further review of ED Physician #2's note dated 9/16/17 at 11:19 PM revealed, ...Primary Impression: Depression with suicidal ideation...Secondary Impressions: Acute psychosis...

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #2 on 9/16/17 at 9:50 PM which documented, ...I certify that this person is subject to involuntary care and treatment ...Depression, tangent thinking, acute mania, suicidal...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Severe depression c [with] SI [suicidal ideation] + plan to kill himself ... Clinical improvement, sx [symptom] reduction...Too high risk + [illegible] for out pt tx [treatment]...

Review of the Emergency Medical Condition (EMC) Identified transfer form signed by a physician (illegible signature) revealed, ...MEDICAL CONDITION: Diagnosis: Suicidal ideation...Obtain level of care/service unavailable at this facility. Service: psychiatric services...Receiving Facility...[Hospital B]...Time of Transfer: 0700 [7:00 AM]...Date: 9/20/17...

There was no documentation the on-call psychiatrist had performed an assessment of Patient #2 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 81 hours and 38 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

7. Medical record review revealed Patient #3 (MDS) dated [DATE] at 11:11 AM for complaint of ...Hallucinations, auditory, Suicidal ideation... Patient #3 had TN [Tennessee] Care UHC [United Healthcare] Medicaid insurance.

ED Physician #3's note dated 6/21/17 at 11:25 AM revealed ED Physician #3 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, ...Patient has a history of schizoaffective disorder...has been out of her psychiatric medications for about 3 weeks. She is now having auditory hallucinations with suicidal content. Her hallucinations instruct her to overdose on her remaining medications... Further review of ED Physician #3's note dated 6/21/17 at 4:35 PM revealed, ...Primary Impression: Schizoaffective disorder...Secondary Impressions: Auditory hallucinations, Suicidal ideation...

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by the ED Physician #3 on 6/21/17 at 2:00 PM which documented, ...I certify that this person is subject to involuntary care and treatment...Pt reports a history of schizoaffective disorder...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Pt presents with auditory hallucinations with suicidal content...Pt needs hospitalization for safety and psychiatric stabilization...

A nurse's note dated 6/21/17 at 11:12 AM documented, ...PER EMS PT [patient] HAS NOT TAKEN HER PSYCH MEDS [medications] FOR 2 WEEKS, 2 DAYS AGO SHE STARTED HEARING VOICES TO OD [overdose] ON HER PILLS AND KILL HERSELF. PT STATES THAT SHE IS SEEING THE DEVIL...

Review of the Emergency Medical Condition (EMC) Identified transfer form signed by a physician (illegible signature) revealed, ...MEDICAL CONDITION: Diagnosis: Psychosis, SI [suicidal ideation]...Obtain level of care/service unavailable at this facility. Service: psych...Receiving Facility...[Hospital B]...Date: 6-24-17...Time: 1610 [4:10 PM]...

There was no documentation the on-call psychiatrist had performed an assessment of Patient #3 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 76 hours and 59 minutes.

8. Medical record review revealed Patient #4 (MDS) dated [DATE] at 1:54 PM for complaint of ...Depressed ... Patient #4 had TN Care Bluecare Medicaid insurance.

ED Physician #4's note dated 2/17/17 at 2:11 PM documented ED Physician #4 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, ...HAS BEEN OFF MEDS FOR ABOUT 6 WEEKS AND HAVING SI CURRENTLY. HX OF THE SAME WITH ATTEMPTS MORE THAN ONCE IN THE PAST... Further review of ED Physician #4's note dated 2/17/17 at 4:38 PM revealed, ...WILL NEED PSYCH EVAL [evaluation] AND 6404 SINCE DANGER TO SELF...Primary Impression...Adjustment disorder with depressed mood...

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #4 on 2/17/17 at 2:15 PM which documented, ...I certify that this person is subject to involuntary care and treatment...HISTORY OF DEPRESSION...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Deterioration due to mental illness to point of inability to care [for] self, at significant risk to health...Treatment likely to prove beneficial in symptom reduction...Condition is likely to deteriorate further without treatment...Adequate evaluation requires a secure setting...

Review of the Emergency Medical Condition (EMC) Identified transfer form signed by a physician (illegible signature) revealed, ...MEDICAL CONDITION: Diagnosis: Depression, SI...Obtain level of care/service unavailable at this facility. Service: Psychiatric Care...Receiving Facility...[Hospital B]...Time of Transfer: 1022 [10:22 AM]...Date: 2-20-17 [2/21/17]...

There was no documentation the on-call psychiatrist had performed an assessment of Patient #4 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 92 hours and 28 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

9. Medical record review revealed Patient #5 (MDS) dated [DATE] at 1:16 PM for complaint of ...Suicidal ideation ... Patient #5 had TN Care Bluecare Medicaid insurance.

ED Physician #5's note dated 2/20/17 at 1:34 PM documented ED Physician #5 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, ...[Patient #5] requesting heroin detox [detoxification]. Is also suicidal - states she wants to blow her brains out with a gun... Further review of ED Physician #5's note dated 2/20/17 at 2:37 PM revealed, ...Will require psychiatric evaluation...Primary Impression: Suicidal ideation...

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #5 on 2/20/17 at 1:30 PM which documented, ...I certify that this person is subject to involuntary care and treatment...Previous psychiatric hospitalization s...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Suicidal ideation with a well-formed plan for self harm as follows: Using firearm...Habitual use of drugs to the point of deterioration or death...In my opinion, the patient is at continued risk of self-harm in not placed under involuntary committment [commitment]...Condition is likely to deteriorate further without treatment...Treatment likely to prove beneficial in symptom reduction...Inability to contract for safety...

A nurse's note dated 2/20/17 at 1:21 PM documented, ...PT VERBALIZES MULTIPLE DRUG USE HISTORY, PT STATES SUICIDAL IDEATION, STATES 'I DONT WANNA LIVE ANYMORE'...

Review of the Emergency Medical Condition (EMC) Identified transfer form signed by a physician (illegible signature) revealed, ...MEDICAL CONDITION: Diagnosis: SI...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital B]...Time of Transfer: 1025 [10:25 AM]...Date: 2/24/17...

There was no documentation the on-call psychiatrist had performed an assessment of Patient #5 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 94 hours and 9 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

10. Medical record review revealed Patient #6 (MDS) dated [DATE] at 7:07 PM for complaint of ...Suicidal ideation ... Patient #6 had TN Care UHC Medicaid insurance.

ED Physician #6's note dated 5/19/17 at 7:27 PM documented ED Physician #6 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, ...[Patient #6] WITH HX OF BIPOLAR DISORDER WHO PRESENTS WITH SUICIDAL IDEATION WITH PLANS TO OVERDOSE WITH MEDICATION... Further review of a physician's note dated 5/19/17 at 10:19 PM revealed, ...Primary Impression: Suicidal ideation... Further review of ED Physician #6's note dated 5/23/17 at 4:36 AM revealed, ...Pt unable to go to [Hospital B] 2/2 [secondary to] PICC [peripherally inserted central catheter] which was initially not conveyed to us, now pt on list for [Hospital A psychiatric campus] in am [AM]...

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by Licensed Professional Counselor #1 on 5/19/17 at 2:15 PM which documented, ...I certify that this person is subject to involuntary care and treatment...History of psychiatric hospitalization s at [Hospital D], [Hospital E] & [Hospital A's psychiatric campus]...current diagnosis of [DIAGNOSES REDACTED][not otherwise specified]...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Patient has SI w/ plan to OD on medication, slit wrists, or walk into traffic...Patient has continued access to lethal means...In my opinion patient poses an imminent threat to self if not placed under an involuntary commitment...Treatment likely to prove beneficial in symptom reduction...Current presentation places self & others at too high risk of injury...

A nurse's note dated 5/19/17 at 7:10 PM documented, ...PER EMS, PT HERE WITH SI, NEEDS CLEARANCE FOR [Hospital A's psychiatric campus]...PT HAS PLAN TO OVERDOSE WITH PILLS...PICC LINE TO LEFT AC [antecubital]...

Review of the Emergency Medical Condition (EMC) Identified transfer form signed by a physician (illegible signature) revealed, ...MEDICAL CONDITION: Diagnosis: Suicidal ideation...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital B]...Time of Transfer: 0225 [2:25 AM]...Date: 5/23/17... Further review of an Emergency Medical Condition (EMC) Identified transfer form signed by a physician (illegible signature) revealed, ...MEDICAL CONDITION: Diagnosis: Suicidal...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital A's psychiatric campus]...Time of Transfer: 1300 [1:00 PM]...Date: 5/24/17...

There was no documentation the on-call psychiatrist had performed an assessment of Patient #6 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 113 hours and 53 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

11. Medical record review revealed Patient #7 (MDS) dated [DATE] at 5:37 PM for complaint of ...Altered mental status ... Patient #7 was uninsured.

ED Physician #7's note dated 9/28/17 at 8:20 PM documented ED Physician #7 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, ...[Patient #7] was seen earlier today by mobile crisis for unclear reason, was cleared home with his mother, and mother later called EMS for continued altered mental status...EXAM...NEURO [neurological]...Questionably intoxicated on marijuana with giggles and perseveration on the connectedness of life...PSYCH...Poor insight and judgment...Speaking to visual hallucinations when left alone in the room which is not consistent with simple marijuana intoxication... Further review of ED Physician #7's note dated 9/28/17 at 11:37 PM revealed, ...Primary Impression: Acute psychosis...Secondary Impressions: Marijuana use...

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #7 on 9/28/17 at 6:00 PM which documented, ...I certify that this person is subject to involuntary care and treatment...no reported psychiatric diagnosis...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...acute psychosis...Would benefit from psychiatric care including symptom reduction...Unable to treat as an outpatient...

A nurse's note dated 9/28/17 at 6:50 PM documented, ...MOTHER STATES 'HE IS JUST NOT RIGHT, HE WAS admitted TO AN ER ON TUESDAY, EVALUATED BY MOBILE CRISIS AND SENT TO [Hospital B] AND THE PSYCHIATRIST EVALUATED HIM THERE AND SENT HIM HOME STATING THAT HE JUST NEEDED TO DETOX [detoxify] FROM POT, BUT I KNOW SOMETHING IS JUST OFF WITH HIM'...

Review of the Emergency Medical Condition (EMC) Identified transfer form signed by ED Physician #8 revealed, ...MEDICAL CONDITION: Diagnosis: Acute psychosis...Obtain level of care/service unavailable at this facility. Service: Psychiatry...Receiving Facility...[Hospital B]...Time of Transfer: 2200 [10:00 PM]...Date: 10/1/17...

There was no documentation the on-call psychiatrist had performed an assessment of Patient #7 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 76 hours and 23 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

12. Medical record review revealed Patient #8 (MDS) dated [DATE] at 5:13 PM for complaint of ...I want to detox from alcohol... Patient #8 was uninsured.

ED Physician #8's note dated 7/17/17 at 5:40 PM documented ED Physician #8 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, ...[Patient #8] states he needs help to get off alcohol because he is afraid that he will die if he does not stop drinking...He has been to rehabilitation recently and just started drinking again about 3 weeks ago... Further review of a physician's note dated 7/17/17 at 8:00 PM revealed, ...case manager spoke with the patient about options for outpatient detox. After this the patient stated he wanted to lay down on the railroad tracks or walk into traffic if he was discharged from the ED today... Further review of ED Physician #8's note dated 7/17/17 at 8:30 PM revealed, ...the patient is now extremely agitated and has been threatening multiple staff members... Further review of a physician's note dated 7/18/17 at 12:36 AM revealed, ...Primary Impression: Depression...Secondary Impressions: Alcohol abuse, Suicidal ideation...

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #8 on 7/17/17 at 8:00 PM which documented, ...I certify that this person is subject to involuntary care and treatment...Active symptoms of [DIAGNOSES REDACTED]...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Suicidal ideation with well-formed plan for self harm as follows: Walking into active traffic or lay on railroad tracks...In my opinion, the patient is at continued risk of harm to others if not placed under involuntary commitment...Condition is likely to deteriorate further without treatment ...Treatment likely to prove beneficial in symptom reduction...Adequate evaluation requires a secure setting...

A nurse's note dated 7/17/17 at 5:30 PM documented, ...PT IS ALCOHOLIC, DRINKS BEER EVERY DAY AND TIRED OF LIVING THIS WAY, HAS HAD SI, WENT THROUGH 30 DAY REHAB [rehabilitation] IN THE PAST AND RELAPSED, STATES HE HAS HAD A LOT TO DRINK TODAY... Further review of a nurse's note dated 7/17/17 at 5:36 PM revealed, ...SUICIDE ASSESSMENT...PATIENT SAYS THAT HE WISHES HE WAS NEVER BORN...PATIENT STATED THAT HE LOST HIS JOB RECENTLY...

Review of the Emergency Notes revealed the following: ...07/17/17 2003 [8:03 PM]...MD ASKED ME TO GIVE RESOURCES TO THIS PATIENT FOR SUBSTANCE ABUSE. I WALKED UP TO HIS BEDSIDE AND HE WAS ON HIS PHONE WITH A NURSE AT ANOTHER [Hospital A's corporation] FACILITY WHERE HIS SIGNIFICANT OTHER IS LOCATED. THE NURSE ON THE PHONE WAS GIVING INSTRUCTION THAT THEY DO NOT HAVE PHONES IN THE ROOM AND HIS SIGNIFICANT OTHER WAS GIVEN HIS MESSAGE. THIS MAN SCREAMED OUT AT THE NURSE (I HEARD ALL THIS COMMOTION AS HE HAD HIS PHONE ON SPEAKER). HE SCREAMED THAT SHE WAS VIOLATING HIS CIVIL RIGHTS AND CURSED HER WITH A 'FUCK YOU! I KNOW MY RIGHTS AND ILL [I'll] HAVE YOU REPORTED. I AM A SECURITY GUARD AT DILLARD AND I KNOW WHO TO CALL!' I WAS AT HIS BEDSIDE WHEN HE GOT OFF THE PHONE-AND HE WAS VERY ANGRY WITH THE ANSWER HE GOT FROM ANOTHER FACILITY. HE IMMEDIATELY STARTED BEING BELLIGERENT WITH ME. HE ASKED ME 'WHAT THE HELL DO YOU WANT?' I TRIED TO RE-DIRECT AND SPOKE OF A POSITIVE ANSWER FOR HIS NEEDS OF FINDING A DETOX BED FOR HIS SUBSTANCE ABUSE. HE HAS TOLD MD THAT HE WAS NOT SUICIDAL AND WAS NOT HOMICIDAL. NOW, HE WANTS TO 'LAY ON THE RAILROAD TRACKS' OR JUMP INTO TRAFFIC! HE SAID I HAVE NO PLACE TO GO AND NOW 'SHE-(SIGNIFICANT OTHER) IS GOING TO GET A PLACE FOR HER PROBLEM SO I AM SUICIDAL. I DON'T WANT TO LEAVE NOW. IF I LEAVE I WILL HURT MYSELF!' I LET MD KNOW. HER PLANS WILL BE TO COMPLETE AN [a] 6404 AND WILL KNOWLEDGE THAT IT WILL BE RESCINDED WITH PLANS FROM MOBILE CRISIS. SECURITY AWARE AND NURSES AWARE...07/17/17 2028 [8:28 PM]...THIS PATIENT IS NOW DEMANDING TO LEAVE AND IS CALLING 'SOMEONE' TO COME PICK HIM UP. SECURITY NOTIFIED. THIS PATIENT AGGRESSIVE AT BEDSIDE. THREATENING TO NOW 'LEAVE, AND SO WHATEVER HE NEEDS TO DO TO GET OUT OF HERE' BODY LANGUAGE AGGRESSIVE WITH FINGERS GOING INTO A FIST, AND OPENING THE FIST FOR US TO SEE THE INTENT. MD AWARE. HE TORE HIS GOWN OFF AND THREW IN THE FLOOR, DEMANDED HIS PHONE. DEMANDED HIS RIGHTS BE 'UPHELD'...07/18/17 0425 [4:25 AM] THIS PATIENT IS NOW MEDICALLY CLEARED AND READY FOR PSYCH PROCESS TO BEGIN...HE IS ASKING WHY HE IS HERE. I WILL DISCUSS THIS CASE WITH MD...

Rreview of the Emergency Medical Condition (EMC) Identified transfer form signed by a physician (illegible signature) revealed, ...MEDICAL CONDITION: Diagnosis: Suicidal Ideation...Obtain level of care/service unavailable at this facility. Service: Psychiatric Care...Receiving Facility...[Hospital B]...Time of Transfer: 0425 [4:25 AM]...Date: 7-21-17...

There was no documentation the on-call psychiatrist had performed an assessment of Patient #8 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 83 hours and 12 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

13. Medical record review revealed Patient #9 (MDS) dated [DATE] at 5:25 AM for complaint of ...PSYCH... Patient #9 was uninsured.

ED Physician #7's note dated 7/16/17 at 5:41 PM documented ED Physician #7 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, ...[Patient #9] with known anxiety disorder and major depressive disorder reports weeks of worsening depressed mood, especially bad in the last few days with suicidal ideation including a plan to shoot herself or record car [wreck her]...PSYCH...Tearful, actively suicidal...Marginal insight and judgment... Further review of ED Physician #7's note dated 7/17/17 at 6:00 AM revealed, Additional Medical History...Anxiety, depression, [DIAGNOSES REDACTED], cavernous [DIAGNOSES REDACTED], seizures, hypertension, chronic pain, migraines, fibromyalgia...6404 was filed by myself for suicidal ideation. She has already been evaluated by mobile crisis who feels that she needs inpatient treatment...Primary Impression: Suicidal ideation...Secondary Impressions: Migraine...

A Certificate of Need for Emergency Involuntary Admission (6404) was not present in the patient's medical record.

A nurse's note dated 7/16/17 at 5:28 AM documented, ...SENT FROM [Hospital A's psychiatric campus] FOR CLEARANCE AND PLACEMENT... Further review of a nurse's note dated 7/16/17 at 5:49 AM revealed, ...SUICIDE ASSESSMENT...PT STATES SHES BEEN HAVING THESE THOUGHTS FOR ABOUT A WEEK...PT STATES SHE HAS PLANS 'DIFFERENT OPTIONS' BUT HAS BEEN TRYING TO FIGHT THEM OFF...

Rreview of the Emergency Medical Condition (EMC) Identified transfer form signed by a physician (illegible signature) revealed, ...MEDICAL CONDITION: Diagnosis: SI...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital B]...Time of Transfer: 1646 [4:46 PM]...Date: 7-19-17...

There was no documentation the on-call psychiatrist had performed an assessment of Patient #9 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 59 hours and 21 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

14. Medical record review revealed Patient #10 (MDS) dated [DATE] at 10:06 PM for complaint of ...bipolar disorder... Patient #10 was uninsured.

ED Physician #9's note dated 10/13/17 at 10:57 PM documented ED Physician #9 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, ...[Patient #10] presents today with issues with bipolar disorder. Family member is here and says he has been delusional. He has been giving his money away to people. this has made him homeless. He also sent them a note saying he is suicidal... Further review of ED Physician #9's note dated 10/14/17 at 12:37 AM revealed, ...history of bipolar. off meds. delusional, destructive behavior. evidence of psychosis...Primary Impression: Bipolar disorder...

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #9 on 10/14/17 at 12:35 AM which documented, ...I certify that this person is subject to involuntary care and treatment...Active symptoms of [DIAGNOSES REDACTED]...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...worsening psychosis 2/2 [secondary to] bipolar with delusional and paranoid behavior...In

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies, Medical Staff Bylaws, Medical Staff Rules and Regulations, Medical Staff On-Call Schedules, medical record review and interview, the facility failed to provide patients who presented to the Emergency Department (ED) with an appropriate Medical Screening Examination (MSE) within the capabilities of the hospital's emergency department and ensure patients presenting with psychiatric disorders were assessed by the hospital's on-call psychiatrists in order to determine if an emergency psychiatric condition existed for 30 of 32 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) patient records reviewed who had presented to the ED seeking treatment.

The findings included:

1. Review of the facilty's EMTALA [Emergency Medical Treatment and Labor Act] Tennessee Medical Screening Examination and Stabilization Policy revealed, ...To establish guidelines for providing appropriate medical screening examinations (MSE) and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA...An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED)...The MSE must be completed by an individual...qualified to perform such an examination to determine whether an EMC [emergency medical condition) exists ...If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity of the facility, or an appropriate transfer as defined by and required by EMTALA. Stabilizing treatment shall be applied in a non-discriminatory manner...no different level of care because of...payment source or ability, or any other basis prohibited by federal, state or local law...

Review of the facility's EMTALA Transfer Policy revealed, ...To establish guidelines for...providing an appropriate transfer to another facility of an individual with an emergency medical condition (EMC), who requests or requires a transfer for further medical care and follow-up to a receiving facility ...Transfer of Individuals Who Have Not Been Stabilized...If an individual who has come to the emergency department has an EMC that has not been stabilized, the hospital may transfer the individual only if the transfer is an appropriate transfer...Higher Level of Care...A receiving hospital with specialized capabilities or facilities that are not at the transferring hospital (including...behavioral health units...) must accept an appropriate transfer of an individual with an EMC who requires specialized capabilities or facilities if the hospital has the capacity to treat the individual...

2. Review of the facility's MEDICAL STAFF BYLAWS reviewed 7/19/16 revealed, ...The Medical Staff shall provide services as applicable, to patients admitted or otherwise treated at [Hospital A] which includes the [Hospital A's psychiatric campus]...To provide patients with the quality of care that is commensurate with acceptable standards and available community services...To monitor and enforce compliance with these Bylaws, Rules and Regulations and hospital policies...

3. Review of the facility's MEDICAL STAFF RULES AND REGULATIONS reviewed 7/19/16 revealed, ...EMERGENCY SERVICES...All persons seeking emergency services and care will receive a medical screening examination and evaluation by a physician or a qualified medical person as designated by hospital policy...If the physician on call is requested by the emergency department physician to see an unassigned patient who has presented to the emergency department for treatment or evaluation, the on call physician must respond, regardless of the patient's ability to pay for any service...Patients with conditions whose definitive care is beyond the capabilities of the Hospital shall be referred to the appropriate facility, when in the judgment of the attending Physician the patient's condition permits such a transfer. Patient transfers shall be in accordance with EMTALA regulations...

4. Review of the facility on-call schedule revealed a psychiatrist was on call 24 hours a day 7 days a week during the time each of the 30 of 32 patients were in the ED.

5. Medical record review revealed Patient #1 presented to the Emergency Department (ED) at Hospital A on 10/21/17 at 7:31 AM for complaint of ...Aggressive behavior, Hallucinations, auditory, schizophrenia... Patient #1 had out of state Medicaid insurance.

Physician Assistant #1's note dated 10/21/17 at 7:58 AM documented Physician Assistant #1 initiated a Medical Screening Examination (MSE) which included: a History of Present Illness (HPI), a Risk of Psychiatric Illness, a Review of Systems (ROS), a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, ...He [Patient #1] is evasive with questions, but upon further discussions with family, they state that he has been having difficulties with voices, commands, and auditory hallucinations. He has been more aggressive recently and is hard to control at home. They attempted to take him to [Hospital A's psychiatric campus], but was instructed to come to the emergency department for medical clearance... Further review of Physician Assistant #1's note dated 10/21/17 at 4:05 PM revealed, ...Patient is having acute psychosis, with auditory hallucinations. Patient needs completion of psychiatric monitoring and treatment to ensure stabilization...Primary Impression: Acute psychosis ...Secondary Impressions: Auditory hallucinations, Schizophrenia...