HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure an appropriate transfer. See deficiency cited at A2409.

Based on document review and interview, it was determined for 1 of 1 Patient (Pt. #1), with an involuntary admission petition from the Emergency Department's (ED) Transferring Hospital, the Hospital failed to ensure an appropriate transfer.

Findings include:

1. On 3/6/18 at 11:20 AM, Hospital's policy titled, "Transfer of Patient to Other Facilities for Continuing Medical Treatment" (revised 9/2014) was reviewed. The policy required, "3. No patient is transferred to another hospital/ institution without obtaining consent to transfer from the receiving hospital/ institution... 5. Physician to physician consultation preceding the transfer is necessary..."

2. Pt. #1's clinical record was reviewed on 3/5/18 at 10:00 AM. Pt. #1 was a 28 year old male, treated in the ED on 2/23/18, for a complaint of medication administration adjustment.

3. A Medical Screening Exam (MSE) by MD #2 was documented on 2/24/18 at 12:14 AM. Pt. #1's MSE included, "Patient is a 28 year old male who is brought in by EMS [Emergency Medical Services] kicking and screaming. He is threatening all the staff. Throwing punches at our staff. He cannot provide any logical history. Patient reports homicidal thoughts and auditory hallucinations." There were no unusual physical findings. The MSE concluded, "Given that the patient is under custody, he will be taken to [another] Hospital for further workup. He is discharged to CPD [Chicago Police Department] custody. Clinical Impression: Acute psychosis. Condition: Fair." There was no documentation that a Physician at the Receiving Hospital had been contacted and accepted the transfer.

4. The final nursing note on 2/24/18 at 1:06 AM, included, "Geodon [treats schizophrenia] wasted ... order canceled, no longer needed, being transferred to [another Hospital]."

5. On 3/5/18 at 4:30 PM, Pt. #1's clinical record from the Receiving Hospital was reviewed. A physician's progress note dated 2/24/18 at 3:31 AM, included, "The Patient presents with psychiatric problem. Patient brought in by police for agitation... Police officers state that this was very irregular but they did not know what to do with the Patient so they brought him here ..."

6. A nursing progress note the Receiving Hospital dated 2/24/18 at 4:48 AM, included, "Patient alert and oriented, in the custody of CPD... Patient was sent over from [the Transferring Hospital] for involuntary admission without any formal endorsement to the Physician. Certificate and Petition was signed by someone at [the Transferring] Hospital."

7. On 3/6/18 at 12:00 PM, a phone interview was conducted with Pt. #1's Attending ED Physician (MD #2) from the Transferring Hospital. MD #2 stated that Pt. #1 displayed psychiatric symptoms that required psychiatric services. Four or 5 police accompanied Pt. #1 to the Hospital and MD #2 asked them what was the protocol for a psychiatric patient in police custody. The police called their Supervisor for instructions. MD #2 followed the CPD protocol by discharging Pt. #1 to the CPD. MD #2 stated that this was a discharge and not a transfer, so a physician at the Receiving Hospital was not contacted.

8. E #3 completed an involuntary admission petition on 2/24/18 at 12:00 AM. The petition included, "Emergency inpatient admission by certificate (405 ILCS 5/3-600). The Respondent [Pt. #1] is currently detained in a mental health facility or hospital... I assert that [Pt.#1] is a person with mental illness who because of his or his illness is reasonably expected, unless treated on an inpatient basis, to engage in conduct placing such person or another in physical harm or in reasonable expectation of being physically harmed ... [is] in need of immediate hospitalization for the prevention of such harm ..."

9. The Attending Physician (MD #2) who examined Pt. #1, completed an Inpatient Certificate, dated 2/24/18 at 12:15 AM. The Certificate included, " ... I have personally examined the above-named individual [Pt. #1] ... Based on the forgoing examination it is my opinion that her or she is a person with mental illness who because of his or her illness is reasonably expected, unless treated on an inpatient basis, to engage in conduct placing such person or another in physical harm or in reasonable expectation of being physically harmed ... is in need of immediate hospitalization for the prevention of such harm ..."

10. On 3/5/18 at 12:10 PM, an interview was conducted with the ED Chairperson (MD #1). MD #1 stated that the Physician (MD #2) who examined Pt. #1 was a "seasoned doctor." MD #1 discharged Pt. #1 to the CPD. If Pt. #1 had been a transfer, the transfer protocol would have been followed. MD #1 stated that a patient can be discharged when involuntarily admitted and in police custody.

11. On 3/5/18 at 3:15 PM, a phone interview was conducted with the Crisis Counselor (E #3). E #3 stated Pt. #1 was having auditory hallucinations and "had to be admitted or he could harm someone." Pt. #1 needed inpatient psychiatric treatment. Armed police were "outside his room all the time." E #3 stated Pt. #1 was discharged to go with the police to another Hospital, and E #3 did not know if it was safer to transport Pt. #1 by ambulance or with the police.

12. On 3/6/18 at 12:00 PM, a phone interview was conducted with MD #2. MD #2 stated that Pt. #1 was discharged from the Hospital to police custody and no ambulance was utilized to transport Pt. #1 to the Receiving Hospital.