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Based on interviews and record reviews, it was determined that the facility failed to comply with 42 CFR 489.24(e)(2) in regard to an appropriate transfer for 5 of 22 sampled patients (Patients: #1, #2, #15, #19, #21). The facility failed to provide an appropriate transfer for pediatric/adolescent psychiatric patients for whom the facility did not have the capability to admit. The facility failed to send to the receiving facility all medical records (or copies thereof) related to the emergency condition, failed to provide documentation related to the risks and benefits of the transfer and failed to send the transfer documentation to the receiving hospital.

Refer to A 2409.

Based on interviews and record reviews, it was determined the facility failed to ensure that the receiving hospital had agreed to accept transfer of one patient for further psychiatric evaluation (Patient #21) in the selected sample of twenty-two patients who were transferred out of the facility. It was also determined that the facility failed to send to the receiving facility medical records related to the emergency condition with which the individuals presented for five patients (Patient #1, #2, #15, #19 #21) of twenty-two patients who were transferred out of the facility .

Findings include:

Review of facility policy # 100-020, Transfer/Receiving Patient Policies, revealed it is the responsibility of the nurse to make sure all forms have been completed prior to transfer to include: ER 63, Patient Transfer Consent/Refusal, ER 64, COBRA II Certification of Information for Transferring a Patient, HIM 2, Authorization to Disclose Health Information, and ER 107, Refusal of Medical Screening Examination.

Review of Patient #1's medical record revealed he/she was 16 years old and presented to the emergency room on 07/28/12 at 1:36 AM with suicidal attempt by overdose. Review of the medical record revealed that Patient #1 received a medical screening examination and that the emergency medical condition was stabilized. Further review of the record revealed that the Emergency Department (ED) physician at the facility spoke with the Advanced Practice Registered Nurse (APRN) at the receiving hospital who accepted Patient #1 for admission. Review of the medical record reveals that Patient #1 was discharged to his/her parents for transport to the receiving hospital at 6:12 AM. Review of the record revealed that the transferring hospital failed to send appropriate documentation, the medical record and the transfer certification to the receiving hospital.

Review of Patient #2's medical record revealed he/she was 11 years old and presented to the emergency room on 07/25/12 at 1:47 PM with homicidal ideations . Review of the medical record revealed that Patient #2 received a medical screening examination and that the emergency medical condition was stabilized. Further review of the record revealed that the Registered Nurse (RN) at the facility spoke with intake staff at the receiving hospital who accepted Patient # 2 for further evaluation. Review of the medical record reveals that Patient #2 was discharged to the local police department for transport to the receiving hospital at 8:01 PM. Review of the record revealed that the transferring hospital failed to send the psych hospital the appropriate documents including the medical record and the certificate of transfer form.
Review of Patient # 15's medical record revealed he/she was 17 years old and presented to the emergency room on 03/13/12 at 1:45 PM with depression. Review of the medical record revealed that Patient #15 received a medical screening examination and that the emergency medical condition was stabilized. Further review of the record revealed that the Behavioral Health nurse at the facility spoke with the staff at the receiving hospital who accepted Patient #15 for further evaluation the record did not indicate the name of the staff spoke to at the receiving hospital. Review of the medical record reveals that Patient #15 was discharged to local police department for transport to the receiving hospital at 8:56 PM. Review of the record revealed that the transferring hospital did not send the receiving hospital documentation of the Emergency Department evaluation, including the history, the examination, and the psych consult. Additionally there was no certificate of transfer form with the patient and no documentation of who the accepting physician was.

Review of Patient # 19's medical record revealed he/she was 13 years old and presented to the emergency room on 03/05/12 at 10:46 AM with suicidal attempt by overdose. Review of the medical record revealed that Patient #19 received a medical screening examination and that the emergency medical condition was stabilized. Further review of the record revealed that the Behavioral Health staff at the facility spoke with the receiving facility who accepted Patient #19 for further evaluation, but the record failed to indicate the names of the staff who were spoken to. Review of the medical record reveals Patient #19 was discharged to parents for transport to the receiving hospital at 2:06 PM. Review of the record revealed that the transferring hospital did not send the receiving hospital the medical record including the lab studies, no certificate of transfer and no indication of the risks and benefits of transfer. Additionally, there was no information regarding which MD had accepted the patient at the receiving hospital.

Review of Patient # 21's medical record revealed he/she was 14 years old and presented to the emergency room on 02/21/12 at 9:42 AM with an intentional drug overdose . Review of the medical record revealed that Patient #21 received a medical screening examination and that the emergency medical condition was stabilized. Further review of the record revealed it contains no evidence that the receiving hospital was contacted by the facility and agreed to accept transfer of Patient #21. Review of the medical record reveals that Patient #21 was discharged to local police department for transport to the receiving hospital at 12:30 PM. Review of the record revealed that the transferring hospital did not send the receiving hospital appropriate documentation regarding the MSE, no lab results, no evidence of the risks and benefits of the transfer and no transfer forms/certification. Additionally, there was no documentation that the receiving hospital was contacted.

Interview with Psychiatric Access Registered Nurse (RN), on 08/09/12 at approximately 3:38 PM revealed she assessed Patient #1 for psychiatric status. She stated that the facility does not provide inpatient care for pediatric or adolescent psychiatric patients. She further stated that she spoke with the house supervisor at the receiving hospital to let her know that Patient #1 required further psychiatric evaluation and would be transported to the receiving hospital by his/her parents. She indicated the house supervisor was aware the APRN had accepted Patient #1 for admission.

An interview with the emergency room physician on 08/09/12 at approximately 4:10 PM, revealed that he completed the medical screening examination for Patient #1. He stated that he cleared the patient medically and then called for a nurse from Psych Access to conduct the psychiatric examination. He indicated that he remembered speaking to someone at the receiving hospital. He further stated that as the patient was being discharged, someone came to him and stated that the receiving hospital stated that discharge papers were not enough and that they needed a statement that the patient was medically cleared. He indicated he wrote on a prescription pad that the patient was medically cleared. He stated that he did not think this was a transfer as the patient was discharged to the parents for transport to the receiving hospital.

An interview with the Manager of Accreditation Services on 08/08/12 at approximately 3:45 PM and on 09/09/12 at approximately 10:57 AM, revealed that the receiving hospital does not take direct admits of adolescent patients and will not accept a transfer. She further stated that the facility does not consider that a patient is " transferred " unless there is a "Doc to Doc" consult with the receiving hospital which results in the receiving hospital agreeing to admit a patient. She stated that is why the patients are discharged from the emergency room and coordination is made between our emergency room and the receiving facility to arrange for further psychiatric evaluation of the patient. She stated that patients transported to facilities by police or parents when arrangements have been made with the receiving hospital for further psychiatric evaluation are considered "discharges" and not "transfers." She further stated paperwork would not accompany the patient if the patient is discharged to another facility.

An interview with the Advanced Practice Registered Nurse (APRN) of the receiving hospital on 08/10/12 at approximately 8:55 AM revealed that the house supervisor of the receiving hospital made him aware that that the transferring hospital wanted to do a "Doc to Doc," which is when practitioners from the transferring and receiving hospitals discuss a potential transfer. He indicated that a "Doc to Doc" should not be done if the facility is not transferring the patient. He further indicated that when a "Doc to Doc" is done and the patient is accepted, the transfer of the patient would require the EMTALA paperwork.

An interview with the Director of Social Services for the receiving hospital, on 08/10/12 at approximately 10:32 AM revealed that Patient # 1 had been accepted for admission as a result of a "Doc to Doc" consult which she understood to mean the patient was being transferred to their facility and that all EMTALA paperwork should accompany the patient. She further stated that the only documentation provided by the transferring hospital was a prescription pad page which stated the patient "medically cleared."

Information gathered during the investigation, revealed the facility did not have a clear definition for the terms discharge or transfer and that the two terms have been used interchangeably and in the case of Patient #1, his/her medical record states the patient had been discharged, however, also documents the facility had arranged for admission to another facility. Review of patient files revealed inconsistencies in sending the required COBRA paperwork with transferred patients. Patients' #1, #2, #15, #19, and #20 were transferred to other facilities without COBRA/EMTALA paperwork.

Based on interviews and record reviews, it was determined the facility failed to ensure that the receiving hospital had agreed to accept transfer of one patient for further psychiatric evaluation (Patient #21) in the selected sample of twenty-two patients who were transferred out of the facility. It was also determined that the facility failed to send to the receiving facility medical records related to the emergency condition with which the individuals presented for five patients (Patient #1, #2, #15, #19 #21) of twenty-two patients who were transferred out of the facility .

Findings include:

Review of facility policy # 100-020, Transfer/Receiving Patient Policies, revealed it is the responsibility of the nurse to make sure all forms have been completed prior to transfer to include: ER 63, Patient Transfer Consent/Refusal, ER 64, COBRA II Certification of Information for Transferring a Patient, HIM 2, Authorization to Disclose Health Information, and ER 107, Refusal of Medical Screening Examination.

Review of Patient #1's medical record revealed he/she was 16 years old and presented to the emergency room on 07/28/12 at 1:36 AM with suicidal attempt by overdose. Review of the medical record revealed that Patient #1 received a medical screening examination and that the emergency medical condition was stabilized. Further review of the record revealed that the Emergency Department (ED) physician at the facility spoke with the Advanced Practice Registered Nurse (APRN) at the receiving hospital who accepted Patient #1 for admission. Review of the medical record reveals that Patient #1 was discharged to his/her parents for transport to the receiving hospital at 6:12 AM. Review of the record revealed that the transferring hospital failed to send appropriate documentation, the medical record and the transfer certification to the receiving hospital.

Review of Patient #2's medical record revealed he/she was 11 years old and presented to the emergency room on 07/25/12 at 1:47 PM with homicidal ideations . Review of the medical record revealed that Patient #2 received a medical screening examination and that the emergency medical condition was stabilized. Further review of the record revealed that the Registered Nurse (RN) at the facility spoke with intake staff at the receiving hospital who accepted Patient # 2 for further evaluation. Review of the medical record reveals that Patient #2 was discharged to the local police department for transport to the receiving hospital at 8:01 PM. Review of the record revealed that the transferring hospital failed to send the psych hospital the appropriate documents including the medical record and the certificate of transfer form.
Review of Patient # 15's medical record revealed he/she was 17 years old and presented to the emergency room on 03/13/12 at 1:45 PM with depression. Review of the medical record revealed that Patient #15 received a medical screening examination and that the emergency medical condition was stabilized. Further review of the record revealed that the Behavioral Health nurse at the facility spoke with the staff at the receiving hospital who accepted Patient #15 for further evaluation the record did not indicate the name of the staff spoke to at the receiving hospital. Review of the medical record reveals that Patient #15 was discharged to local police department for transport to the receiving hospital at 8:56 PM. Review of the record revealed that the transferring hospital did not send the receiving hospital documentation of the Emergency Department evaluation, including the history, the examination, and the psych consult. Additionally there was no certificate of transfer form with the patient and no documentation of who the accepting physician was.

Review of Patient # 19's medical record revealed he/she was 13 years old and presented to the emergency room on 03/05/12 at 10:46 AM with suicidal attempt by overdose. Review of the medical record revealed that Patient #19 received a medical screening examination and that the emergency medical condition was stabilized. Further review of the record revealed that the Behavioral Health staff at the facility spoke with the receiving facility who accepted Patient #19 for further evaluation, but the record failed to indicate the names of the staff who were spoken to. Review of the medical record reveals Patient #19 was discharged to parents for transport to the receiving hospital at 2:06 PM. Review of the record revealed that the transferring hospital did not send the receiving hospital the medical record including the lab studies, no certificate of transfer and no indication of the risks and benefits of transfer. Additionally, there was no information regarding which MD had accepted the patient at the receiving hospital.

Review of Patient # 21's medical record revealed he/she was 14 years old and presented to the emergency room on 02/21/12 at 9:42 AM with an intentional drug overdose . Review of the medical record revealed that Patient #21 received a medical screening examination and that the emergency medical condition was stabilized. Further review of the record revealed it contains no evidence that the receiving hospital was contacted by the facility and agreed to accept transfer of Patient #21. Review of the medical record reveals that Patient #21 was discharged to local police department for transport to the receiving hospital at 12:30 PM. Review of the record revealed that the transferring hospital did not send the receiving hospital appropriate documentation regarding the MSE, no lab results, no evidence of the risks and benefits of the transfer and no transfer forms/certification. Additionally, there was no documentation that the receiving hospital was contacted.

Interview with Psychiatric Access Registered Nurse (RN), on 08/09/12 at approximately 3:38 PM revealed she assessed Patient #1 for psychiatric status. She stated that the facility does not provide inpatient care for pediatric or adolescent psychiatric patients. She further stated that she spoke with the house supervisor at the receiving hospital to let her know that Patient #1 required further psychiatric evaluation and would be transported to the receiving hospital by his/her parents. She indicated the house supervisor was aware the APRN had accepted Patient #1 for admission.

An interview with the emergency room physician on 08/09/12 at approximately 4:10 PM, revealed that he completed the medical screening examination for Patient #1. He stated that he cleared the patient medically and then called for a nurse from Psych Access to conduct the psychiatric examination. He indicated that he remembered speaking to someone at the receiving hospital. He further stated that as the patient was being discharged, someone came to him and stated that the receiving hospital stated that discharge papers were not enough and that they needed a statement that the patient was medically cleared. He indicated he wrote on a prescription pad that the patient was medically cleared. He stated that he did not think this was a transfer as the patient was discharged to the parents for transport to the receiving hospital.

An interview with the Manager of Accreditation Services on 08/08/12 at approximately 3:45 PM and on 09/09/12 at approximately 10:57 AM, revealed that the receiving hospital does not take direct admits of adolescent patients and will not accept a transfer. She further stated that the facility does not consider that a patient is " transferred " unless there is a "Doc to Doc" consult with the receiving hospital which results in the receiving hospital agreeing to admit a patient. She stated that is why the patients are discharged from the emergency room and coordination is made between our emergency room and the receiving facility to arrange for further psychiatric evaluation of the patient. She stated that patients transported to facilities by police or parents when arrangements have been made with the receiving hospital for further psychiatric evaluation are considered "discharges" and not "transfers." She further