HospitalInspections.org

Based on record review and interview the facility staff failed to appropriately transfer/discharge a patient to a behavioral health hospital for continued treatment in 1 of 20 medical records reviewed (Patient (Pt) #1), in a total sample of 20 medical records reviewed.

Findings Include:

Review of policy and procedure #19290 titled, "...EMTALA" last reviewed 04/24/2023 revealed the following:
-"A physician...may...Transfer a stable patient from the hospital to a Recipient hospital for ongoing care if the following are met: ...The patient had an EMC (emergency medical condition), but the physician...has determined with reasonable clinical confidence that the patient has been stabilized and has reached the point where the patient's continued care, including diagnostic work-up, treatment, and/or other follow-up care could reasonably be performed in another setting."
-"...An unstable patient may be transferred if hospital staff provide stabilizing treatment for the patient's EMC within the Capacity and Capabilities of the hospital and...A physician must certify that the medical benefits expected from transfer outweigh the risks and describe the reasons for and potential risks and benefits of the transfer by completing the applicable areas on the Patient Transfer Form..."
-"A representative of the Recipient Hospital must confirm prior to transfer that: The Recipient Hospital has available space and qualified personnel to treat the patient and agrees to accept the Transfer and to provide appropriate medical treatment; and Hospital staff should document any communication with the Recipient Hospital, including the date and time of the Transfer request and the name of the person accepting the Transfer in the patient's medical record."
-"the hospital staff shall send to the Recipient Hospital copies of all pertinent medical records available at the time of Transfer, including:...A copy of the completed Patient Transfer Form."

Review of Pt #1's ED Patient Care Timeline revealed the following documentation:
08:02 AM: "Patient arrived in ED"
08:27 AM: "Chief Complaint...Drug Overdose"
08:27 AM: "ED Triage Notes...Pt arrives w(with)/husband for overdose of Benadryl, husband reports he found empty bottle of 50 mg (milligram) diphenhydramine sleep aid, not sure how many were taken. Pt is alert but confused, admits to self harm attempt. Pt agreeable to inpatient treatment. Husband also reports pt drank 4-5 beers and 2 large shots of whiskey."
08:40 AM: "Patient roomed in ED.."
08:49 AM: "ED Notes...Poison control advises follow up EKG (electrocardiogram) in 3 hours w/4 hours of observation."
09:03 AM: "Psych Assessment...Safety...Interventions: Intake notified; initiate and explain suicide precautions to patient; Constant visual observations; Provider notified...
09:22 AM: "Specimens Collected...Salicylate Level..."
09:27 AM: "Completed Electrocardiogram (EKG) 12-lead Completed."
10:22 AM: "Tele-Intake Behavioral Health Assessment complete. Will triage with on-call psychiatrist for recommendations, if needed. At this time patient is not voluntary for BH (behavioral health) inpatient treatment. Recommending crisis/police to be called...Addendum 1545 (3:45 PM): report given to second shift tele-intake RN (registered nurse)."
10:30 AM: "Salicylate Level Resulted...5.6 mg/dl..."
11:01 AM: "ED Notes...Writer reached out to Crisis at the request of BH intake RN."
12:15 PM: "ED Notes...Crisis at bedside. Pt attempting to leave. Writer convinced patient to get back into bed and speak with HHS (crisis team)."
12:35 PM: "ED Notes...Poison Control follow up, advises to recheck salicylate level after 4 hours, if above 4, level should be rechecked every 2 hours until downward trend is noted."
12:48 PM: "ED Notes...Pt attempting to leave ED. Public Safety stopped patient from leaving. HHS confirms ED (Emergency Detention)...PD (Police Department) at bedside."
2:55 PM: "Salicylate Level Resulted...5.0 mg/dl..."
3:41 PM: "ED Notes Addendum...Poison Control called and stated that pt will need a salicylate level redraw in 2-4 hours."
4:28 PM: "Team Member Assigned...(Physician F) assigned as Admitting (attending physician)."
4:28 PM: "Order Placed...Admission--Assign to Observation."
4:28 PM: "Bed Requested...Medical/Surgical."
4:38 PM: "Departure Condition...admission discussed; patient verbalized understanding..."
4:44 PM: "Patient admitted...To department...Med Surg West."
5:24 PM: Physician order to discharge Pt #1 to the behavioral health hospital.
10:41 PM: Pt #1 was discharged to the behavioral health hospital with police.

Review of Pt #1's Columbia Suicide Severity Rating Scale dated 10/31/2023 at 10:51 AM revealed the following:
- "Wish to be dead (past month)...Yes."
- "Non-Specific Active Suicidal Thoughts (past month)...Yes."
- "Active Suicidal Ideation with Specific Plan and Intent (past month)...Yes."
- "Active Suicidal Ideation with Specific Plan and Intent Description (past month)...Overdose on pills and cut wrist."

Review of Pt #1's admission History and Physical (H & P) by Physician F dated 10/31/2023 at 4:09 PM revealed, "Patient presents with suicide attempt...Patient says she took alcohol and a half bottle of Benadryl because she was having 'sleep issues'. Did desire to harm herself...Patient says she does want to get help and agrees to go to inpatient psych. Patient's salicylate level 5.0 down from 5.6, Poison Control is involved and say she is medically cleared once salicylate level is below 4.0." Per review of the H & P Assessment and Plan, "...trend salicylate q (every) 4 hours, patient may be transferred to inpatient psych once salicylate level below 4.0. currently chaptered (emergency detention)...1-1 sitter."

Review of Pt #1's Discharge Summary by Physician F signed on 10/31/2023 at 5:25 PM revealed, "Immediately after pt was transferred to the floor poison control called and said patient could be discharged to (behavioral health hospital) without further lab draws. Pt had no incidents in the interim. Pt discharged in stable condition." Pt #1's discharge Follow up/Instructions revealed, "Follow-up with inpatient psych team, cleared by poison control." Pt #1's discharge Disposition was documented as "Inpatient Psych."

Per review of Pt #1's Care Timeline, Pt #1 was discharged to the behavioral health hospital on 10/31/2023 at 10:41 PM (approximately 6 hours after inpatient admission).

Per review of Pt #1's medical record, there was no documentation of the following:
-Patient Transfer Form being completed by the physician as per policy.
-Communication with the receiving hospital and the receiving hospital accepting Pt #1 for admission.
-Nurse to Nurse communication with the receiving hospital to ensure continuity of care.

Per interview with Physician F on 12/15/2023 beginning at 3:50 PM, Physician F stated that he/she was the inpatient admitting physician for Pt #1 on 10/31/2023. Physician F confirmed there was no Patient Transfer Form completed and Physician F did not contact the receiving hospital to ensure they were aware of the patient transfer request and that there was an accepting physician. Physician F stated that Pt #1 was admitted as an inpatient observation to monitor the Salicylate levels and ensure Pt #1 was medically stable for discharge to the behavioral health hospital. Per Physician F, Poison Control called as soon as the patient arrived to the inpatient unit, and stated that Pt #1 was ok for discharge based on the lab results trending down. Physician F stated that he/she was under the impression that ED staff had already contacted the behavioral health facility and that Pt #1 was accepted and cleared to be discharged.

Per interview with Quality Director (Dir) B on 12/15/2023 at 1:12 PM, Dir B stated that based on the hospital's investigation into this incident, it was determined that there was a miscommunication between hospital staff and Poison Control. Per Dir B, team was informed by Poison Control that Pt #1 was cleared and was ready for discharge, however hospital staff did not double check that the behavioral health hospital had accepted Pt #1. Per Dir B the hospital staff had not received communication from the behavioral health hospital that there was an accepting physician and space available. Dir B confirmed that there was no documentation of RN to RN communication. Dir B confirmed that Pt #1 was admitted to the hospital and placed in observation status, with plans to transfer to the behavioral health hospital once Pt #1 was medical cleared.

Per telephone interview with Pt #1 on 12/19/2023 at 1:57 PM, Pt #1 was transferred to the behavioral health hospital via police officers. Per Pt #1 when she/he arrived to the behavioral health hospital the staff was not aware that she/he was coming, and the paperwork was not ready. Pt #1 stated that there was a room available, but staff still had to clean it. Pt #1 stated that she/he waited 45 minutes before staff was ready to go through the admission process.