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Based on medical record review and staff interview, the hospital failed to ensure that one of 30 sampled patients presenting to the emergency room received stabilizing treatment prior to discharge (Patient #2) and failed to ensure two of 30 sampled patients transferred to another hospital were accepted by the receiving hospital and failed to ensure the patients' medical records were sent with the transfer. (Patients #1 and #8) The hospital further failed to ensure patients were informed of the need for transfer. This affected three of thirty patients whose medical records were reviewed, (Patient #2, #1 and #8).

Findings included:

The facility failed to provide Patient #2 stabilizing treatment to prevent the patient from harming him/herself prior to discharge.

Please refer to 42 CFR 489.24(d)(1-3); A2407 - Stabilizing Treatment - for more information.

The facility failed to ensure the receiving hospital had agreed to accept the transfer and to provide medical treatment of Patient #s 1 and 8 and failed to ensure all medical records related to the patient's condition were sent with the patient.

Please refer to 42 CFR 489.24(e)(1)-(2); A2409 - Appropriate Transfer - for more information.

Based on medical record and staff interview the hospital failed to ensure that one of 30 sampleted patients received stabilizing treatment to prevent self harm prior to discharge. (Patient #2) The sample was thirty records reviewed.

Findings include:

The medical record for Patient #2 was reviewed on 10/04/10. Patient #2 presented to the emergency department on 09/20/10 at 3:09 P.M. The patient reported he/she was seeking treatment because "I feel like maiming myself." The patient was sent to the psychiatric emergency services department. A nursing triage intake information form was completed by the psychiatric emergency service department (PES). The nurse documented an assessment at 3:50 P.M. The assessment stated; "the patient had a history of bipolar disorder". The nurse further stated the patient had a history of cutting his/her leg since 1990, now thinking of cutting his/her face so "everyone will see the pain in my heart." The nurse noted the patient wanted to stay one week because "he doesn't feel safe".

Further review of the medical record contained a form titled; "PES physician evaluation". This form was completed by a certified nurse practitioner (Staff J). Staff J documented the patient planned to "maime self to release anger and hurt", but documented the patient had no suicidal ideation (thoughts). The nurse practitioner described the patient's mood as "depressed" and listed recent increased stressors because of marital difficulties and financial issues. The nurse practitioner wrote a narrative note which stated the patient did not meet the requirements for hospitalization. The medical record did not contain further assessment regarding the patient's statement of a desire to "maim" him/herself, or any documentation the patient was questioned regarding how the patient planned to maim him/herself. The medical record lacked documentation of any further information regarding the patient's threat to cut his/her face, any plan he/she had to cut him/herself or an assessment of the patient's ability to do so.

The medical record lacked documentation of any attempts by Staff J or other PES Staff members to contact this patient's psychiatrist to obtain the patient's history to more accurately assess the patient's risk of harming him/herself. The medical record did not contain documentation that the PES staff provided stabilizing treatment to prevent the patient from harming him/herself.

The medical record noted the patient was discharged from the hospital at 5:00 P.M. The medical record lacked evidence a determination the patient was not at risk of physical harm to him/herself had been made prior to discharge. The patient was given discharge instructions to follow up with his/her therapist. The medical record lacked evidence any stabilizing treatment had been provided prior to his/her discharge from the hospital

An interview was conducted with the Nurse Practitioner who had provided care for Patient #2 on 09/20/10 (Staff J). Staff J was asked if the patient posed a substantial risk of harm to him/herself. Staff J stated he/she did not feel the patient was at any risk of harming him/herself. Staff J continued to say if he/she had seen any evidence of past behavior of cutting, the patient may have been deemed to be a risk to him/herself. Staff J, upon questioning, confirmed he/she did not assess the patient for signs of cutting such as scars, recent wounds, etc. Staff J stated he/she did not look at the patient's legs, which were the location the patient had stated he/she preferred to cut. Staff J further stated he/she did not recall how long the patient's shirt sleeves were, so was unable to recall if the patient's wrists/arms were assessed for evidence of injury.

Patient #2 presented to a second hospital on 09/20/10 at 6:30 P.M., where the patient was assessed by a physician as being at substantial risk of harm to him/herself and was admitted to psychiatry services.

Based on medical record review and staff interview, the facility failed to provide documentation that patient transfers to another facility were first accepted by the receiving hospital and failed to ensure the patients' medical records accompanied the patients transferred. The hospital further failed to ensure patients were informed of the need for transfer and orders were obtained from the physician for transfer. This involved two (#1 and #8) patients of 30 patient medical records reviewed.

Findings included:

The medical record for Patient #1 was reviewed on 10/05/10. Patient #1 presented to the emergency department on 08/21/10 at 8:30 P.M. with complaints of suicidal and homicidal thoughts. The medical record revealed the patient had called the police and reported his/her thoughts of strangling people. A nursing note dated 08/21/10 at 11:40 P.M. stated the patient was assessed by the physician and who wrote; "to be admit when bed available ... due to insurance not covered at the facility". The entry lacked explanation of where the patient was to be admitted. The medical record lacked physicians orders to transfer or admit the patient.

The next nursing note in the medical record was dated 08/22/10 at 1:10 A.M. and stated; "Report called to Christ". There was no documentation that the receiving hospital accepted the patient.

A nursing flow sheet revealed an entry dated 08/22/10 at 2:10 A.M. which stated, "D/C to Christ." The entry lacked information regarding how the patient was transferred, the reason for the transfer and lacked evidence the receiving hospital had agreed to accept the transfer of the patient and to provide medical treatment. The medical record lacked evidence the patient had been informed of the transfer, or if all medical records related to the patient's condition were sent with the patient.

The medical record for Patient #8 was reviewed on 10/05/10. Patient #8 presented to the emergency department on 09/25/10 at 1:16 P.M. with complaints of thoughts of hurting him/herself. The medical record revealed the patient was assessed to represent a substantial and immediate risk of serious physical injury to him/herself and a psychiatric hold was signed by the emergency room physician.

The medical record revealed a nursing entry dated 09/26/10 at 1:25 A.M. which read "Report called to (name) at Clermont County hospital." The medical record lacked evidence of the reason a report was called to another hospital.

A nursing flowsheet, also dated 09/26/10 at 1:25 A.M., revealed the patient was transferred to another hospital. The medical record lacked; evidence of the reason for the transfer, an order to transfer, evidence the receiving hospital had agreed to accept the transfer of the patient and to provide medical treatment. The medical record lacked evidence the patient was informed of the transfer and lacked evidence that all medical records related to the medical condition of the patient were sent to the receiving hospital.

Interview of Staff B on 10/05/10 at 3:30 P.M. revealed the transfer "may have been for location." Staff B was unable to identify the exact reason for transfer and confirmed the medical record lacked evidence the receiving hospital had accepted the patient, how the transfer was effected and by whom.

These findings were reviewed with and confirmed by Staff A, B and D on 10/04/10 at 4:00 P.M.