HospitalInspections.org

Based on medical record reviews, audio record review, document reviews, and interviews, the facility failed to ensure a safe discharge for 1 of 24 patients reviewed (Patient #1). The facility failed to have a comprehensive Emergency Department (ED) discharge policy and procedure, which included coordination of ambulance discharges/transfers which are completed by Emergency Department staff.

Findings included:
Patient ID #1 arrived to Facility A ED on 10/2/24 at 00:22 am, under a Emergency Detention Order from Ft. Bend Sheriff department and accompanied by group home staff member, with complaints of suicidal and homicidal ideation. He had normal vital signs and was triaged and had a medical screen evaluation initiated. Records reflect he had a social work mental health assessment which revealed the patient had Attention Deficit Hyperactivity Disorder and no other mental health history. He was assessed and ofund to be no longer with suicidal or homicidal ideation. Medical record stated that it was believed that Patient ID #1 had an episode of aggression following a pillow fight. The medical team and mental health social worker felt it was appropriate to discharge patient home to the group home and provided outpatient follow-up mental health resources. The group home staff agreed with the plan of care presented. The ED charge nurse, Staff ID # 79, called the contracted EMS agency and stated a need for an ambulance to bring patient to Facility B as she stated this was the origin of patient. Facility A medical record stated the patients disposition was "discharged." There was no Memorandum of Transfer located in Facility A Medical Record and no documentation of acceptance by FAcility B administration.

Record Review:
Review of Contracted EMS Ambulance Medical Records:
"Prehospital Care Report Summary stated Date:10/02/2024 Call #:0198 Booklet:59900978 Branch: Houston Time Zone:GMT-06:00 Central.
Call Information:
Billing Disposition: Treated/Transported
Unit Disposition: Patient Contact Made
Patient Evaluation/Care Disposition: Patient Evaluated and Care Provided
Crew Disposition: *Initiated and Continued Primary Care
Transport Disposition: *Transport by This EMS Unit (This Crew Only)
Unit #: XB971 - XB971, Ground-Ambulance Trip Type: Initial Trip
Service Requested: Hospital-to-Hospital Transfer
Incident Facility: (Redacted) Facility A with physcial address listed . NPI: 1184078743
Incident Location Type: Hospital
Receiving Facility: (Redacted - Facility B with physical address listed)
Destination Type: Hospital Emergency Department
Dest. Reason: Specialist Care
Condition of Patient At Destination: Unchanged
Loaded Mileage: 21.0 (Total Mileage: 21.0)
Resource Code: Psychiatric Care
Call Received: 04:20:11
Dispatched: 06:46:51
En Route: 06:47:00
At Staging Area:
On Scene: 07:43:59
Patient Contact: 07:46:10
Transfer of EMS
Patient Care:
Left Scene: 08:10:49
At Destination: 08:52:38

Narrative History Text from EMS Run Record:
XB971 was dispatched non-emergency to (redacted) Facility A to transfer a patient for mental/psychiatric care at (redacted) Facility B for a higher level of mental/psychiatric care not available at Facility A.
HPI: Patient was brought in by police under EDO (Fort Bend Sheriff) from patient's group home with c/o: SI/ HI. Patient made statement of "wanting to harm other residents and staff members."
Diagnosis: Behavioral Issues. Per Facility A nurse patient is returning to facility for continued treatment ...."
Patient contact was made; Upon entering the patient's room.... Patient report was given & patient paperwork, nurse contacted case worker for MOT: crew was informed MOT was not necessity due to patient had come from Facility B."

Audio Transcript from Facility A ED Charge Nurse Staff ID #79 to EMS Dispatch reviewed:
EMS (company redacted) dispatch:" Inaudible, how can I help?"
Facility A Charge Nurse: "Hey this is (redacted, Staff ID #79) at Facility A (redacted). I need a truck please."
EMS dispatch: "Where is it going to?"
Facility A Charge Nurse: "Redacted (Facility B) in the med center"
EMS dispatch: "Is that like a psych facility?"
Facility A Charge Nurse: "Yes"
EMS dispatch: "Female or Male"
Facility A Charge Nurse: "Male"
EMS dispatch: "Voluntary?"
Facility A Charge Nurse: "Yes, yeah he came from that facility"
EMS dispatch: "Less than 300 pounds?"
Facility A Charge Nurse: "Yes"
EMS dispatch: "Last name? First Name?"
Facility A Charge Nurse: (Redacted) Patient ID #1, name was spelled out
EMS dispatch: "What's your name? "
Facility A Charge Nurse: Redacted (Staff ID #79 provides her first name)
EMS dispatch: "Your title?"
Facility A Charge Nurse: "I'm the charge nurse ..."
EMS dispatch: "Where we going?"
Facility A Charge Nurse: "To redacted (Facility B)"
EMS dispatch: "Do you have a room number there?"
Facility A Charge Nurse: "No, he's just going to intake?"
EMS dispatch: "Diagnosis?"
Facility A Charge Nurse: "Behavioral problem"


Facility B Medical Record Review of Patient ID #1 was performed for date of service 10/2/24 at 09:35 am by Staff Physician # 99. The Emergency Department physician note stated "Per the admin and EMS, (Facility A) then sent/transferred the patient to us for a psychiatric evaluation under the false belief that (Redacted -Facility B) was an inpatient psych facility. Please note that our ED never received any communication or transfer request from TCH-West prior to the patient's arrival."

Facility A occurrence log identified Patient ID #1 with an occurrence entered by ED Manager Staff ID # 79 on 10/2/24 and this was labeled "transfer issue." This occurrence entry was signed off by ED Manager Staff ID #79, who was also functioning in the charge role per facility records, as "reviewed and completed." However, Facility A failed to complete a thorough internal investigation, which fully identified the problem with the discharge via EMS services and therefore failed to implement corrective actions to reduce the chance of this occurring again.

Policy Reviews:
Facility A's " Transfer of Patients to and from (Redacted - Facility A)'s
Hospital Procedure", version 5, stated "2.2. The Hospital's Mission Control will coordinate all requests for transfers of individuals between Facility A's Hospital and other healthcare facilities. "

Interviews:
Interview with Medical Record Review of Patient ID #1 with Facility A Clinical Specialist #53 on 11/18/24 at 12:35 pm. She confirmed she was unable to locate and Memorandum of Transfer (MOT) form for Patient ID #1 for date of service 10/2/2024. She stated that Physician ID #75 had ordered Patient ID #1 to be discharged and stated she would not expect to locate a Memorandum of Transfer (MOT).

Telephone Interview on 10/29/2024 at 2:30 pm with Facility B CNO Staff ID #100. She stated that Patient ID #1 arrived at the Facility B ED with (redacted) EMS ambulance personnel on a stretcher and companied by a caregiver. She stated that Facility B had no knowledge of the patient's transfer. The house supervisor had not received a transfer request. She stated the facility has an inpatient geriatric psychiatric unit and would not have accepted a teenage patient for inpatient psychiatric care. She stated the patient arrived with no medical records, no MOT (memorandum of transfer form). She stated that the caregiver accompanying patient had requested of Facility A staff for patient to be discharged home and had been told by Facility A staff that "he must be transferred." She stated she called Facility A's Emergency Department Charge Nurse at approximately 10:00 am, when the patient arrived to Facility B for more information, and was told this was a night shift mistake and they had no other information.

Interview with Director of Transfer (also known as "Mission Contol") Center Staff ID # 60 on 11/18/2024 at 12:50 pm. She confirmed there was no evidence of Facility A transfer center involvement in coordination of transfer of care for Patient ID #1 from Facility A to Facility B via EMS service.

Telephone Interview with ED Nurse Manager Staff ID # 79 on 11/18/2024 at 2:25 pm. She stated she was not aware that Facility B was a hospital. She confirmed she is an ED Night Shift Manager at Facility A, who was also functioning in the ED Charge Nurse Role on 10/2/2024 when Patient ID #1 was seen and evaluated. She stated she had called Facility A's contracted EMS service to bring patient to Facility B, after he was discharged from the ED of Facility A, because she believed he had originated from Facility B.

Interview with Director of Accreditation Staff ID # 51 on 11/19/24 at 3:30 pm. She confirmed the facility does not have a policy, procedure or protocol which guides discharge of patients from the ED, utilizing EMS services, and coordinated by ED clinical staff.

Interview with Patient Safety Manager Staff ID # 81 on 11/18/2024 at 2:45 pm. She confirmed that she had signed off on the incident report, which included improper discharge from the ED and allegation of EMTALA violation, based on comment provided by ED Nurse Manager Staff ID # 79 which stated "Address written on MOT was verified with caregiver at bedside. Review of face sheet lists different address from group home." She confirmed she was unaware ED Nurse Manager Staff ID #79 was involved in the patient's care and improper discharge coordination. She confirmed she was unaware that the comments stating" MOT had incorrect address" was inaccurate because there was no MOT for this patient located in the medical record. She confirmed that staff members, involved in reported occurrences, should not be solely responsible for investigation and follow-up. However, confirmed this is not stipulated in facility's occurrence policy."