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Based on policy review, record review and interview, it was determined the hospital failed to provide an appropriate transfer for 1 of 16 (Patient #1) sampled patients who presented to the Dedicated Emergency Department (DED) and were transferred from the hospital to another facility.

The findings included:

1. Review of the facility's " Evaluation and Transfer of Patients with Emergency Medical Condition " policy documented "...Transfers...B.2. The receiving facility has agreed to accept transfer of the individual... "

2. Review of 30 medical records revealed 1 (Patient#1) of the sample was not transferred appropriately to an accepting facility and physician.

3. Refer to findings in deficiency A-2409.

Based on policy review, record review and interview, the hospital failed to provide an appropriate transfer and stabilization for 1 of 16 (Patient #1) sampled patients who presented to the Dedicated Emergency Department (DED) and were transferred to another facility.

The findings included:

1. Review of Hospital #1's " Evaluation and Transfer of Patients with Emergency Medical Condition " policy documented, "...Emergency medical Condition...medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbance and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably result in: Placing the health of the individual...in serious jeopardy...The patient is provided, within capabilities of the staff and facilities available at the hospital, further medical examination and treatment as required to stabilize the medical condition or transfer the patient...If the patient does not require a transfer, then the patient may only be transferred if the physician, or other qualified medical personnel...determines, based on the information available at the time of the transfer, that reasonably expected medical benefits of the transfer outweigh any increased risks from the transfer...The receiving facility: Has available space and qualified personnel for the treatment of the individual, and Has agreed to accept the transfer...Transfer is affected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer...".

2. Medical record review for Patient #1 revealed the 21 year old presented to Hospital #1's dedicated emergency department (DED) on 6/4/16 at 14:12 via Emergency Medical Services (EMS) and Police escort for a drug overdose and attempted Suicide. The patient was found unresponsive in her home, EMS administered Narcan and the patient became alert. Patient admitted to using heroin and intentionally trying to hurt herself in a suicide attempt. The patient reports a history of anxiety, depression and seizures and has been hospitalized the last 3 weeks for severe depression. The area Crisis facility was notified for patient consult.

3. Review of the Crisis facility's "Crisis Assessment" at 17:58 revealed Patient #1 reported it was her intention to end her life when she injected herself with heroin. Patient reported daily substance abuse. "Pt (Patient) currently poses a threat to harm self...continues to be suicidal...patient reported a depressed mood by unknown trigger...patient is in need of stabilization prior to discharge...". The Patient was referred to the Crisis Stabilization Unit located at a local Psychiatric hospital.

Review of the local Psychiatric hospital's Certificate of need for Emergency Involuntary Admission form documented the patient required "direct transportation" to an admitting psychiatric facility based on a face-to-face assessment that determined the patient, "...she continues to be depressed and a high risk for serious bodily injury or death...Patient is currently unstable and unpredictable as she cannot keep herself safe within a secure environment to prevent further deterioration...She is an immediate danger to herself...".

4. At 22:06:10 Nurse #1 at Hospital #1 documented she spoke with the Crisis Stabilization Unit (CSU) and was awaiting a call back from them.

At 22:53:30 the CSU at the local Psychiatric hospital called Hospital #1 and stated someone was on their way to pick the patient up to be transferred to the CSU at the local Psychiatric hospital.

Review of Patient #1's transfer form completed at Hospital #1 on 6/4/16 at 23:09 revealed a physician at the local Psychiatric hospital had accepted the patient's transfer.
On 6/5/16 at 05:18 Nurse #1 at Hospital #1 documented on the patient's transfer form that the patient was now being transferred to Hospital #2 because a nurse from the CSU at the local Psychiatric hospital refused to accept the transfer without a police "booking number" since the patient was escorted by a police officer. There was no documentation a physician was notified of this decision by the nurse.

On 6/5/16 at 05:23:14 Nurse #1 documented the police officer who had escorted Patient #1 to Hospital #1's ED had talked with another police officer at Hospital #2 and they determined to transfer the patient to Hospital #2. There was no documentation of a physician's order to transfer to Hospital #2 or a determination by the Crisis team that Patient #1 could be transferred to Hospital #2 by the police officer.

At 05:37 Patient #1 was transferred from Hospital #1 and taken by police to Hospital #2. There was no documentation a physician had spoken to Hospital #2 regarding the patient's transfer or an acceptance of the transfer by Hospital #2.

5. Review of the ED physician's MSE at Hospital #2 dated 6/5/16 at 07:22 revealed Patient #1 presented to the DED via the police with complaints of suicidal ideation. The ED physician documented the severity of the patient's symptoms were moderate. The ED physician documented, "The patient has been recently seen by a physician at [name of Hospital #1], was transferred without my knowledge or acceptance". The ED physician ordered for Patient #1 to be transferred to the local Psychiatric hospital with the diagnoses of suicide attempt and intentional overdose. At 08:25, Patient #1 was transferred from Hospital #2 to the local Psychiatric hospital.

6. During a telephone interview with Nurse #1 from Hospital #1 on 6/28/16 at 11:00AM the nurse stated the CSU was going to send someone to pick up Patient #1 to transfer the patient to the local CSU at the local Psychiatric hospital. The nurse stated she had given Patient #1 the paperwork to go with her. Later a staff member from the CSU called back and said they could not accept the patient due to the patient having outstanding warrants for arrests. The Police officer who was in the ED with Patient #1 told me Hospital #2 would take Patient #1 and that they had accepted the patient. Nurse #1 stated she did not speak to anyone at Hospital #2 regarding transferring Patient #1.


During a telephone interview telephone with the Charge Nurse (Nurse #2) at Hospital #1 on 6/28/16 at 12:50 PM, the nurse stated Patient #1 was in the ED when he arrived to work. The Crisis facility staff member had already evaluated Patient #1 and was trying to place her in a Psychiatric facility. Patient #1 had outstanding warrants and she had not been placed under arrest when the police brought her to the ED. The nurse stated the Psychiatric hospital had a bed for the patient. The Crisis facility called the police to transport the patient and that is unusual, they (police) don't usually transport from ED to another facility. Patient #1 was still not under arrest. The police decided to take Patient #1 to Hospital #2. The nurse stated normally when a patient is transferred, the ED nurse would contact the receiving ED nurse to give a report of the patient and the ED physician would contact the receiving ED physician to give a report of the patient.

During an interview with the Emergency Nurse Manager on 6/28/16 at 1:19 PM, she stated they typically transfer very few patients unless it's for a higher level of care. The nurse manager stated transfers should follow transfer procedures. If our physicians are transferring is for a higher level of care. If the Crisis facility is helping us with transfers, we are still responsible for the transfer. To my knowledge the police only transfer to a police facility if the patient is under arrest but never to another healthcare facility.

During an interview with Physician #1 at Hospital #1 on 6/28/16 at 1:32 PM, the physician stated that in order to transfer a patient they determine who the accepting facility will be, the accepting physician, and mode the of transfer. The physician stated they would call the receiving physician at the receiving hospital and get a verbal acceptance from them. The physician stated the police were irrelevant in the transfer process and patient transfer should not be by police. The physician stated the police usually ask the ED staff what the plans are for the patient. The physician stated that regardless of where a patient is being transferred there still needs to be physician to physician call. There should be an accepting party at that facility. The physician stated that Patient #1 was still in Hospital #1's ED when his shift ended on 6/5/16.