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Based on staff interview and medical record and document review, the facility failed to provide further stabilizing medical examination and treatment when two of three sampled patients (1, and 19) were placed in restraints without physician orders.

Findings:

Patient 1 was brought to the Emergency Department (ED) at 3:39 p.m., 5/22/13 by law enforcement officers for suicidal ideation and possible alcohol intoxication. The patient been placed on a psychiatric hold for further evaluation.

Patient 1's "Restraint Flow Sheet" indicated soft restraints had been applied to the right wrist and both ankles between 5 p.m. - 6 p.m., 5/22/13. Reasons for the restraints were noted as "combative, threatened staff."

The "Physician's Restraint Orders" form contained Patient 1's demographics sticker and an illegible mark in the "MD [Medical Doctor] Signature" section. The form's "Reason for Restraint," "Type of Restraint," "Date" and "Time" sections were blank.

In a 1 p.m., 5/28/13 interview, the ED Manager (EDM) acknowledged the restraint form had not been completed and the physician signature was illegible.

Patient 19 was brought to the ED by ambulance at 10:15 a.m., 5/6/13 after a neighbor noticed the patient without clothing walking her dog. Patient 19 was combative with responding law enforcement and emergency medical personnel.

Review of the ED physician's 11:10 a.m., 5/6/13 documentation form indicated Patient 19's "History of Present Illness" was "ALOC (altered level of consciousness)" of one day's duration. The form's "Physical Examination" area included a "Psych" section which was blank.

Patient 19's initial 12:15 p.m., 5/6/13 "Nursing Progress Note" stated, "No appearance of discomfort or distress" although 1 milligram of Ativan (a medication to decrease anxiety) was documented as given at 12:10 p.m., 5/6/13. A 1:10 p.m. note read, "Patient alert and oriented...Complained of being out of control earlier today. Patient states that she is calm and relaxed now. Denied wanting to hurt self or others. Patient appears calm and comfortable. NAD [no apparent distress] noted."

Patient 19's nursing "Restraint Flow Sheet " reflected the application of soft restraints to both wrists and ankles between 11 a.m. - noon on 5/6/13. Descriptions of the conditions indicating restraint included "confusion/disoriented, delusional, manic."

Patient 19's "Physician's Restraint Orders" form had a demographics sticker attached but was otherwise blank.

During a 4:30 p.m., 5/28/13 interview, the ED Assistant Manager (AM) acknowledged the physician order form had not been completed.

Article 10.1-1 of the hospital "Medical Staff Rules and Regulations," revised 5/12/13, stipulated, "Restraints shall be instituted only on a practitioner's written or verbal order, which shall be signed within 24 hours...."

Review of the hospital's 9/5/08 "Restraints Policy" reflected, "The decision to use a restraint is based on a comprehensive individual patient assessment...Physician Responsibilities - Patient Assessment: The physician assesses the individual patient's need for restraint...Orders - Physical restraint...require a physician's order...Documentation - The use of restraint is recorded in the medical record, including clinical justification for use."

Based on interview and record review, the hospital failed to ensure requirements were met for the appropriate transfer of eight of eight patients (Patients 1, 3, 6, 8, 19, 20, 21, 22) from the Emergency Department (ED) to an acute psychiatric facility between 4/9/13-5/22/13.

Findings:

In review of an unnumbered hospital policy titled Emergency Transfer Protocol, dated October, 2012, there was stipulation "the physician and staff will abide by all applicable laws and regulations regarding the transfers of patients". The policy further directed the attending physician to sign a certification that, based on the information available at the time of transfer, the medical benefits of treatment at another facility outweighed the increased risks to the patient. The policy further required documentation of a discussion of the transfer, including the risks and consequences, with the patient and the need to obtain the signature of the patient or the patient's representative. The policy instructed staff to send copies of the medical records related to the patient's condition and a transfer summary, signed by the transferring physician, with the patient at the time of transfer.

In review of an unnumbered hospital policy titled Compliance with EMTALA, dated 5/1/08, the ED, in Appendix A, pages 4-5, VI., B., Transfer of Individuals with an Emergency Medical Condition, the Requirement for an Appropriate Transfer was defined as:
"1. The hospital provides medical treatment within its capacity to minimize the risks to the individual's health....
2. The receiving facility has available space and qualified personnel for treatment of the individual; and the receiving facility and receiving physician have agreed to accept the individual....
3. The hospital sends to the receiving facility all medical records (or copies thereof) available at the time of transfer related to the medical condition of the individual, including (i) records related to the individual's emergency condition; (ii) the individual's informed written consent to transfer or the physician certification (or copy thereof); ...."
4. The transfer is effected using proper personnel and equipment...."

ED policy #1502, revised 3/4/13, was reviewed. This policy stipulated that an appropriate informed consent must be obtained and documented prior to transfer. Further direction was given to organize the discharge, transfer forms and applicable medical records to provide information for ongoing care. These included the Physician Authorization for Transfer Form, the Patient Transfer Acceptance or Refusal Form, the Physician Certification for Transfer Form with clearly stated risks and benefits of transfer, the Transfer Order Form and the authorization to Release Medical Information Form. The medical records to be sent included the Emergency Department Treatment Record, Nursing Progress Notes, Laboratory and Diagnostic Imaging results, EKG's and miscellaneous reports and consultation records. The policy defined the requirement to obtain acceptance of the patient by the receiving facility. This would include documentation of the individual accepting the patient, the time and name of person receiving report, the summary of the condition of the patient and vital signs at the time of transfer.

Eight of eight patients who presented to the ED with a psychiatric condition and were transferred to an acute psychiatric facility between 4/9/13-5/22/13 were reviewed.

1. Patient 1, a 27 year old, presented to the ED accompanied by law enforcement on 5/22/13 at 3:39 p.m. with suicidal ideation and intoxication. Patient 1 had been placed on a 5150 (a 72 hour hold) by a sheriff prior to admission and was transferred to an acute care psychiatric facility on 5/22/13 at 7:10 p.m. In review of the medical record, there was no evidence the receiving facility had been contacted for bed availability or had accepted the patient for transfer. There was no documentation the physician had discussed the risks and benefits of the transfer or that the patient (or the patient's representative) had received this information. There was no evidence that copies of the medical record had been sent with the patient at the time of transfer.

2. Patient 3, a 31 year old, presented to the ED accompanied by law enforcement on 5/20/13 at 4:31 p.m. with a history of schizophrenia. Patient 3, who had called 911 from the hospital lobby, stated he heard voices telling him to hurt himself. Patient 3 was transferred to an acute care psychiatric facility on 5/20/13 at 5:11 p.m. In review of the medical record, there was no evidence the receiving facility had been contacted for bed availability or had accepted the patient for transfer. There was no evidence that copies of the medical record had been sent with the patient at the time of transfer.

3. Patient 6, a 21 year old, presented to the ED on 5/18/13 at 1:07 p.m. with suicidal ideation and was placed on a 5150 hold. Patient 6 was transferred to an acute psychiatric facility on 5/18/13 at 4:25 p.m. In review of the medical record, there was no documentation the physician had discussed the risks and benefits of the transfer or that the patient (or the patient's representative) had received this information. There was no evidence that copies of the medical record had been sent with the patient at the time of transfer.

4. Patient 8, a 50 year old, presented to the ED on 5/15/13 at 11:19 p.m. with suicidal ideation and was placed on a 5150 hold. Patient 8 was transferred to an acute psychiatric facility on 5/18/13 at 4:25 p.m. In review of the medical record, there was no documentation the physician had discussed the risks and benefits of the transfer or that the patient (or the patient's representative) had received this information.

5. Patient 19, a 35 year old, presented to the ED with law enforcement on 5/6/13 at 10:15 p.m. with an altered level of consciousness following an episode of bizarre behavior at home. Patient 19 had been placed on a 5150 by a sheriff prior to admission and was transferred to an acute care psychiatric facility on 5/6/13 at 10:35 p.m. In review of the medical record, there was no documentation the physician had discussed the risks and benefits of the transfer or that the patient (or the patient's representative) had received this information.

6. Patient 20, a 22 year old, presented to the ED on 5/28/13 at 10:50 p.m. with suicidal intentions following an overdose of a prescriptive medication. Patient 20 was transferred to an acute psychiatric facility on 5/29/13 at 3:50 a.m. In review of the medical record, there was no documentation the physician had discussed the risks and benefits of the transfer or that the patient (or the patient's representative) had received this information. There was no evidence that copies of the medical record had been sent with the patient at the time of transfer.

7. Patient 21, a 38 year old, with a history of bipolar disorder, presented to the ED on 4/10/13 at 9:25 p.m. with vague complaints of pain, (no medical condition was identified related to the complaints of pain). Patient 21 was very anxious and disoriented and exhibited symptoms of a psychiatric condition. Patient 21 was transferred to an acute psychiatric facility on 4/11/13 at 9:50 a.m. In review of the medical record, there was no evidence the receiving facility had been contacted for bed availability or had accepted the patient for transfer. There was no documentation the physician had discussed the risks and benefits of the transfer or that the patient (or the patient's representative) had received this information. There was no evidence that copies of the medical record had been sent with the patient at the time of transfer.

8. Patient 22, a 55 year old, presented to the ED on 4/9/13 at 5:30 a.m. with suicidal ideation and hallucinations. Patient 22 was transferred to an acute psychiatric facility on 4/10/13 at 12:50 p.m. In review of the medical record, there was no evidence Patient 22 had been determined to be stable for transfer. In addition, there was no documentation the physician had discussed the risks and benefits of the transfer or that the patient (or the patient's representative) had received this information. There was no evidence that copies of the medical record had been sent with the patient at the time of transfer.

The ED Manager (EDM), in an interview on 5/28/13 at 3 p.m., presented a transfer packet used by the ED titled Inter-Facility Transfer Information. This packet contained multiple forms to be used by the physician to document the reason for transfer, the condition of the patient at the time of transfer and the discussion with the patient or representative of the risks and benefits of transfer. A form was present to be signed by the patient acknowledging they had received information regarding the risks and benefits and had agreed to the transfer. A checklist on the front of the packet was to be used to denote all forms had been completed and appropriate medical records had been sent with the patient to the receiving facility. The MED acknowledged this packet was not being used for patients transferred to acute care psychiatric facilities.

In a concurrent interview with the Deputy Director of Standards and Compliance (DDSC), she stated the policies for transfer, noted above, were only applicable to non psychiatric medical patients being transferred to an acute care facility for a higher level of care.