HospitalInspections.org

Based on record review, policy review and staff interview, it was determined the facility failed to comply with the requirements of 489.24. Deficiencies were cited regarding stabilization (A 2407 ) and appropriate transfer (A 2409).

Based on record review and staff interview, it was determined the facility failed to provide stabilization within the capabilities of the facility for 1 (#1) of 20 sampled patients.

Findings include:

Patient #1, presented to the facility, accompanied by local law enforcement on 8/17/13. The the officer had enacted the Baker Act for involuntary psychiatric evaluation. Review of the Triage form revealed that the officer stated that the patient had complained that he thought his blood sugar was high. A point of care blood glucose was performed with a reading of 354. The normal range is 70 - 110. Review of physician orders revealed an order for a urinalysis (UA) with culture if indicated. The report from the UA revealed there was 3 + bacteria, packed white blood cells and 30 - 40 red blood cells. These were all abnormal findings and indicative of a urinary tract infection. Review of the medical record revealed there were no interventions regarding these abnormal findings related to the UA and the blood glucose prior to the patient's being transferred to a non-medical psychiatric facility for psychiatric evaluation. The physician's documentation included a "Clinical Impression.....1. Acute Anxiety, 2. Delusion UTI." This verifies that the MSE was not complete and or medically cleared by the physician because he was aware the patient had a UTI (Urinary Tract Infection) and failed to treat it while the patient was in the Emergency Department.

During an interview on 11/7/13 at approximately 10:30 a.m., the Chief Nursing Officer confirmed the above findings.

Based on record review, facility policy review and staff interview, it was determined the facility failed to ensure an appropriate transfer for 1 (#1) of 20 sampled patients.

Findings include:

1. Facility's policy "Emergency Medical Treatment and Transfer (EMTALA", no number, effective 9/03, no revision or review, requires that a physician must sign a certification, which includes a summary of the risks and benefits, that, based upon the information available at the time of the transfer, the medical benefits reasonably expected from the provision of the appropriate treatment at another facility outweigh the risk to the individual's condition from effecting the transfer. The facility uses a pre-printed transfer form to document the transfer information.

2. Patient #1 was taken to the facility's Emergency Department (ED) on 8/17/13 by local law enforcement for involuntary psychiatric evaluation under the Baker Act. Review of the list of the facility's available services revealed the facility does not provide psychiatric care. The ED physician documented in the electronic record that the patient would be transferred to a crisis stabilization unit and that the transfer forms were completed, however, a review of the medical record revealed the transfer form was not in the record. There was no documentation of appropriate certification by the ED physician.


3. The Chief Nursing Officer and Risk Manager reviewed the record and communicated with Health Information Management concerning the missing documentation on 11/7/13 at approximately 10:30 a.m., but could find the missing documentation.