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Based on interview, record review and policy review, the hospital failed to follow its policies and procedures when they did not provide further examination and stabilizing treatment within its capacity to minimize the risks of transfer to the patient's health, and the safety of the transport driver, and when qualified personnel and transportation equipment were not used to transfer one patient (#1) out of 30 Emergency Department (ED) sampled cases from May 2020 through March 2021. Patient #1 presented to SoutheastHealth's ED (Hospital A) seeking care for attempted suicide (to cause one's own death), suicidal ideations (SI, thoughts of causing one's own death) and depression (extreme sadness that doesn't go away). Thirty minutes prior to Patient #1 being transferred to Hospital B (affiliated hospital with inpatient psychiatric services), he had an aggressive outburst, and walked into another patient's room and pushed the patient, which was a change in behavior for Patient #1. The patient was not reassessed by staff prior to transport after the aggressive outburst, and therefore could not be deemed to have been stabilized prior to transfer. The patient was transferred utilizing a behavioral health transportation company in a vehicle with one driver. During the transport to Hospital B, Patient #1 attacked the driver by placing a blanket around the driver's neck and face, causing the driver to pull off the road and call for assistance. The hospital's average monthly ED census over the past six months was 2,347.

Findings included:

1. Review of the hospital's policy titled, "EMTALA: Emergency Medical Screening Treatment and Labor Act," revised 09/22/20, showed the following:
- The hospital was required to provide for an appropriate transfer of the individual if either the individual requests the transfer or the hospital does not have the capability or capacity to provide the treatment necessary to stabilize the EMC.
- Prior to transfer, appropriate medical screening and treatment has been provided, within the capability of the hospital, to minimize the risk of the individual's health.
- A patient will be transferred when the patient has been stabilized such that within reasonable medical probability, no material deterioration of the patient's condition is likely to result from the transfer.
- The transfer is affected through qualified personnel and transportation equipment as required, and the appropriate mode of transportation is determined by the transferring physician, based upon clinical judgement and anticipated needs in route.
- Documentation should reflect an accurate picture of the patient's condition at the time of transfer as well as those measures taken to provide stabilizing treatment and to provide a safe and appropriate transfer of the patient.

Review of the hospital's policy titled, "Behavioral Health Suicide Assessment, Interventions and Precautions," revised 03/20/20, showed the following:
- The hospital will identify patients who are at risk of harming self or others (aborted or unsuccessful suicide attempt or voicing suicidal ideation and/or plans for harming themselves or others), complete an assessment, and implement appropriate care interventions to mitigate the risk of patient harming self or others.
- The ED Nurse completes the behavioral assessment and, if indicated, the suicide risk screening tool by asking, "Are you feeling sad, hopeless or depressed? Have you had a recent loss or life changing event?" If the answer is yes to either question, then ask the additional question, "Do you have thoughts of ending your life today?" If the answer is yes, automatically consider the patient as high risk for suicide and place the patient on 1:1 constant observation.
- Social Services will complete the crisis evaluation to include the Columbia Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) and communicate his/her findings to the ED physician and the patient's primary nurse. Documentation will be completed in the Electronic Medical Record (EMR).
- Patients with a high risk for suicide per the C-SSRS, are to be placed under constant one to one (1:1, continuous visual contact with close physical proximity) observation with suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm).

Review of the hospital's policy and procedure related to a behavioral health medical transport company, revised 02/25/20, showed that a first aid kit, flashlight, road flares and a blanket shall be kept in transport vehicles at all times.

Patient #1's medical record dated 05/08/20, showed that staff failed to follow hospital policy and did not provide further examination and stabilizing treatment prior to the patient's transfer, which resulted in an inappropriate mode of transport. At 6:16 PM, the patient arrived to Hospital A's ED after he attempted suicide by hanging that afternoon. At 6:34 PM, the patient was seen by Staff S, ED Physician, and the assessment was depression and suicide attempt by hanging. A Crisis Evaluation was completed at Hospital A by the Social Worker at 8:33 PM. She documented that the patient was experiencing racing thoughts and said today he felt like he was Jesus, but knew that was delusional (false ideas about what is taking place or who one is). The patient admitted to illegal drug use over the last year and current withdrawal symptoms were anxiety (a feeling of fear or worry experienced intermittently) and hallucinations (seeing or hearing things which are not there). The patient reported he did not want to die, but could not say he would not try again. She recommended acute psychiatric hospitalization. The crisis evaluation did not indicate a C-SSRS score and the patient was not placed on 1:1 observation. Documentation showed that at 10:04 PM, the patient was accepted for admission to Hospital B as a voluntary psychiatric inpatient and the physician signed documents at 10:22 PM, which showed the patient was to transfer by ambulance to Hospital B. On 05/09/20 at 12:15 AM, documentation from security guard video monitoring showed the patient had inappropriate behavior (pushed another patient) and the patient was placed in seclusion per Staff S, ED Physician. There was no behavioral health screening exam reassessment performed by a physician or crisis evaluation reassessment by social work staff, after the patient's inappropriate change in behavior. The patient was transferred on 05/09/20 at 12:45 AM, to Hospital B by a behavioral health medical transport company, not by ambulance (During interview, the transportation driver reported that he was not told the patient had a violent outburst 30 minutes prior to transfer). The patient was placed in the backseat of a vehicle, and was alone with only the driver. The patient had a blanket in the backseat and during transport, the patient used the blanket to choke the driver. The driver was able to safely bring the vehicle to the side of the road and call for assistance. The driver stated the patient reported to him that he was hearing voices and that the devil told him to assault the driver. The patient was taken to Hospital B by police and while there, he refused to sign documents to be voluntarily admitted to the hospital. He signed the document for admission as "Lucifer." The patient was evaluated in the ED at Hospital B, and documents were signed for a court-ordered involuntary admission to Hospital C where he was admitted for nine days with a diagnosis of Psychotic disorder (a disorder characterized by false ideas about what is taking place or who one is).

The hospital failed to provide Patient #1 with further examination and stabilizing treatment prior to transfer, which resulted in an unsafe mode of transportation for a patient with an emergency psychiatric condition. This led to Patient #1 having an aggressive episode toward the transportation driver while they were en route, putting both the patient and driver at risk.

See A-2409 for additional information.

Based on interview and record review, the hospital failed to provide a safe transfer with qualified personnel and equipment for one patient (#1), out of 30 Emergency Department (ED) records reviewed from May 2020 through March 2021. Patient #1 had attempted suicide (to cause one's own death), was delusional (having false ideas about what is taking place or who one is), and became aggressive toward another patient 30 minutes prior to transfer from SoutheastHealth ED (Hospital A) to Hospital B (affiliated hospital with voluntary inpatient psychiatric services). The patient was not reassessed by staff prior to transport after the aggressive outburst, and therefore could not be deemed to have been stabilized prior to transfer. Instead of using an ambulance, the hospital elected to transport the patient by a behavioral health transportation company, and without giving an adequate patient report to the driver. This failure placed the patient and driver at increased risk for their safety during transport. The hospital's average monthly ED census over the past six months was 2,347 and the average monthly transfer of patients over the past six months was 60.

Findings included:

1. Review of Patient #1's Hospital A ED record showed he was a 19 year old male, who presented to the ED by private vehicle on 05/08/20 at 6:16 PM, with complaints of attempted suicide (to cause one's own death) by hanging earlier in the afternoon, suicidal ideations (SI, thoughts of causing one's own death) and depression. He reported depression (extreme sadness that doesn't go away) for years but had never been evaluated. There was no documentation that showed an ED nurse completed a suicide risk screening for the patient, the patient was not placed on one to one (1:1, continuous visual contact with close physical proximity) monitoring as indicated for high-risk suicide assessment, and was placed in a video monitored room. The patient was seen by Staff S, ED Physician, at 6:34 PM, and diagnosed with depression and suicide attempt by hanging. The patient reported that he sometimes heard music in his head and felt an intense connection with other people. A Crisis Evaluation (questions about ones psychiatric history, past events, frequency of events and how they have affected an individual's mental health) was completed by Staff H, Social Worker, at 8:33 PM. She documented that in addition to the suicide attempt, the patient was experiencing racing thoughts (consistent, persistent and often intrusive thoughts that come in rapid succession) and he felt like he was Jesus, but knew that was delusional. The patient admitted to illegal drug use over the last year and current withdrawal symptoms were anxiety (a feeling of fear or worry experienced intermittently) and hallucinations (seeing or hearing things which are not there). The patient reported he did not want to die, but he could not say he would not try again. She recommended acute psychiatric hospitalization. The crisis evaluation did not indicate a Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) score and the patient was not placed on 1:1 observation. A urine drug screen (UDS, a test that analyzes urine for the presence of certain illegal drugs and prescription medications) resulted positive for cannabinoids (psychoactive drug from the cannabis plant used primarily for medical or recreational purposes) and amphetamines (an addictive mood altering drug). At 10:04 PM, the patient was accepted for transfer and admission to Hospital B as a psychiatric inpatient. At 10:22 PM, the physician signed the "Transfer Authorization Form" for the patient to be transported by ambulance, as well as the "Certificate of Medical Necessity for Ambulance Transportation," and noted that all other means of transportation were contraindicated based on his suicidal ideation, mental health issue, and because he was a "safety concern." Security documentation dated 05/09/20 at 12:15 AM (30 minutes prior to transfer), showed that the patient was placed on seclusion (confinement of a patient alone in a room where he/she was physically prevented from leaving) per Staff S, ED Physician, for "inappropriate" behavior. At 12:45 AM, Staff J, Hospital A Licensed Practical Nurse (LPN), documented that the patient departed the ED, and was transferred to Hospital B by a behavioral health transport company (not by ambulance). An addendum documented by Staff S, ED Physician, dated 05/12/20 (three days after the patient departed the ED), showed that while the patient awaited transportation to Hospital B (on 05/09/21), he was placed in seclusion after security reported that the patient went into another patient's room and pushed her. Staff S documented that it "seemed like a minor event" because there were no injuries, "but for the safety of other patients he was not allowed to walk the hall after this event." In the end of the addendum, she noted that the decision to transport the patient by the behavioral health transport company was determined "appropriate."

During an interview on 03/31/21 at 1:30 PM, Staff S, Hospital A ED Physician, stated that she remembered Patient #1 as calm, cooperative, and forthcoming with wanting to get help after he had attempted suicide. She remembered being asked by the social worker if the patient could transport by the transportation company for admission to Hospital B, and she agreed. While the patient awaited transfer, she was asked to come to the psychiatric hallway by security because Patient #1 had wandered into another patient's room and pushed the patient. Security had to escort Patient #1 back into his room. She did not witness the incident and she did not reassess Patient #1 or speak to him after the event. She had the security guard close the patient's door and the patient was not allowed to walk in the hallway (seclusion). It seemed to her like a minor incident, and when the transportation company driver arrived, Patient #1 was cooperative and voluntary, so she felt it was a safe option of transportation. When shown the signed certificate of medical necessity for ambulance transportation, and physician transfer authorization form, which indicated ambulance as the mode of transportation, she agreed it was her signature, stated it was a mistake, and that it should have read transportation company as mode of transport.

During an interview on 03/30/21 at 3:05 PM and 04/07/21 at 8:15 AM, Staff J, Hospital A Licensed Practical Nurse (LPN), stated that the hospital had three options for transport: law enforcement, ambulance, or private transportation (such as the behavioral health transport company). After the ED Physician determined the mode of transport for Patient #1, she called and set up the transportation. She agreed the physician transfer authorization form and certificate of medical necessity for ambulance transportation form were signed by the physician and indicated that the patient required an ambulance transfer. She did not recall why Patient #1 was transported by the transportation company instead of the ambulance. She stated that when the transportation company driver arrived, he did not ask for any information about Patient #1 and she did not provide any medical information about the patient due to patient privacy, although she would have provided this information to the ambulance staff if the ambulance had been used. She stated if a patient had any behavior issues, violence towards others or were a harm to themselves, they were not sent by the transportation company, and if she had known the patient had a violent outburst and had been placed in seclusion by security 30 minutes prior to transport, she would not have sent the patient by the transportation company.

During an interview on 04/05/21 at 12:50 PM, County Ambulance Senior Paramedic X, stated that the ambulance service provided "quite a few" behavioral health transfers, and that most were transferred for voluntary admission. The ambulance service always provided two staff members during the transport of behavioral health patients, the driver, and a staff member who monitored, and if necessary, medicated the patient.

There was no documentation in the medical record that Patient #1 was reevaluated after he became aggressive with another patient, to ensure that the patient was not a safety risk during transport by the behavioral health transport company (which provided one staff member for transport, a driver). The hospital had the capability to utilize the county ambulance (which provided two staff members for transport: a driver, and a healthcare professional who could monitor and medicate the patient), which was available to the hospital.

During an interview on 03/31/21 at 4:30 PM, Medical Transportation Company Driver Z, stated that he was called to transport the patient from Hospital A for a direct admit to Hospital B. The report he received from the nurse was minimal, and he was never informed that the patient had an aggressive episode 30 minutes before transfer. The nurse handed him the paperwork and said, "he will be ok." During the transport, the patient tried to kill him by strangling him with a blanket while he was driving, then told the driver that the devil told him to do it. After the event, the patient's demeanor changed completely and he displayed childlike behavior, and was transported on to Hospital B by law enforcement.

During a telephone interview on 03/30/21 at 4:45 PM, Transportation Company Director M, stated that if it had been reported that Patient #1 exhibited aggressive/violent behavior while in the ED, the transportation company would not have agreed to transport the patient.

Review of Patient #1's Medical Record at Hospital B showed that when the patient presented to the ED by law enforcement on 05/09/20 at 2:41 AM, the patient was belligerent and combative. When asked to sign documents for admission, the patient signed his name as "Lucifer" and then refused admission. The patient admitted to suicidal ideations, documents were signed for a court-ordered involuntary admission, and the patient was accepted for transfer and admission to Hospital C (hospital which accepts involuntary psychiatric admissions) at 11:45 AM, with a diagnosis of psychosis (characterized by false ideas about what is taking place or who one is).

During a telephone interview on 03/31/21 at 9:05 AM, Hospital B ED Physician O, stated that upon Patient #1's arrive to the ED, he required a court order for a 96-hour hold (court-ordered evaluation by behavioral health specialists to determine if a person is safe to themselves and others) due to belligerent, combative behaviors, and because he refused to be admitted to Hospital B for inpatient psychiatric care. ED Physician O added that an ambulance should be used to transport even those patients who were cooperative and wanted help, because patients with underlying psychiatric conditions were unpredictable, and their behavior could change quickly.

During a telephone interview on 03/31/21 at 11:40 AM, Staff P, Hospital A ED Physician, stated that if a patient was psychotic (false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature), having loose thought processes and active hallucinations, that patient should be transported by ambulance.

During an interview on 03/31/21 at 8:45 AM, Staff N, Hospital A ED RN, stated that behavioral health patients who were voluntary and agreeable to inpatient admission, could be transported by the transportation company or ambulance, but the ambulance was always the first option. If a patient had been escalating and more on edge during the ED encounter, the transportation company would not be an appropriate mode for transfer.

During an interview on 03/30/21 at 2:11 PM, Staff H, Hospital A Social Worker, stated that the physician decided how a voluntary psychiatric patient was to be transported, and if a physician felt like the patient was threatening or violent, the patient would be transported by ambulance. If a patient scored as high risk on the C-SSRS, they would be 1:1 observation, however, she did not document a score for Patient #1. Staff H added that the patient would have scored a moderate to high risk for danger/suicide.

During an interview on 03/30/21 at 2:30 PM, Staff I, Hospital A Registered Nurse (RN), stated that the ED physician determined the mode of transportation for patients who were transferred, and that patients who were 1:1 observation were not transferred using the transportation service.

During an interview and concurrent record review on 03/30/21 at 12:30 PM, Staff G, Hospital A Case Management and Social Services Director, stated that if a patient was a 1:1, the patient would be transported by ambulance, and after reviewing Patient #1's chart, agreed that the patient was a high risk for suicide and required a 1:1 observation (indicating that the patient should have been transferred by ambulance). Staff G stated that the ED physician was responsible for making the decision on mode of transport for patients who were transferred, but that the transportation company was used to transport voluntary behavioral health patients to other hospitals, and primarily utilized for self-pay patients.

Review of Patient #1's demographic information from Hospital A, showed that the patient was unemployed, uninsured, and self-pay.

The hospital failed to appropriately reassess a suicidal patient that had an aggressive encounter with another patient 30 minutes prior to transfer, which resulted in the failure to provide a safe mode of transportation for a patient with an emergency psychiatric condition. These failures led to Patient #1's aggressive episode toward the transportation driver while they were en route from Hospital A to Hospital B, which placed both the patient and the driver at risk.