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Based on record review and interview, the hospital failed to ensure compliance with 42 CFR 489.20 (l) Compliance with 489.24 and 42 CFR 489.24 (e) (1)-(2) Appropriate Transfer for 1 of 20 patients [Patient #1] when they presented to the hospital on 07/23/2024 for treatment. Patient #1 did not receive an appropriate transfer to an acute care hospital.

Cross refer A2409.

Based on record review and interview, the hospital failed to contact the receiving hospital to inquire about available space and obtain an acceptance for the transfer of 1 of 20 patients [Patient #1].

Findings Included:

Patient #1 was initially evaluated at Hospital A. Hospital A had begun the transfer process due to their inability to accommodate Patient #1's acuity level with their current staffing. Patient #1 signed all transfer paperwork, but the patient was denied by several facilities. Ultimately, Hospital C accepted Patient #1. Hospital A attempted to transfer the patient to Hospital C, but the patient refused transfer to Hospital C and became agitated. Patient #1 made statements that he wanted to kill Hospital A staff and himself. The Police Department was contacted, and Patient #1 was taken into custody on a detention warrant and transferred to Hospital B. Hospital A staff were aware of the transfer to Hospital B but did not complete an MOT [memorandum of transfer], send discharge paperwork or contact Hospital B regarding the transfer.

Interdisciplinary Progress Note completed on 07/23/2024 at 9:35 PM reflected the following, "Conducted pt assessment at 2135-2145 pt did exhibit verbally threatening behavior and expressed SI if pt wasn't admitted."

Interdisciplinary Progress Note completed on 07/23/2024 at 10:43 PM reflected the following, "Called 911 D/T [due to] threatening bx [behavior] towards self. Pt uncooperative w/ [with] transfer out process. Unable to contact additional IP [inpatient] facilities D/T bx."

Interdisciplinary Progress Note completed on 07/23/2024 at 11:03 PM reflected the following, "Pt's transfer started. Hospitals [Hospital C], [Hospital D], [Hospital E], [Hospital F]. Pt signed ROI [release of information] to provide information."

Interdisciplinary Progress Note completed on 07/23/2024 at 11:37 PM reflected the following, "[Hospital C] accepted pt."

Interdisciplinary Progress Note completed on 07/23/2024 at 11:50 PM reflected the following, "Pt declined transfer to [Hospital C]. [Police Department] transported pt to [Hospital B]."

A review of the medical record did not evidence that report, medical records, and/or an MOT were sent to Hospital B.

During an interview on 08/22/2024 at 9:54 AM, Personnel #3 stated [Patient #1] came in and was offered a transfer out. [Patient #1] required a 1:1 and we did not have the staff. This occurred on night shift. [Patient #1] agreed to being transferred out initially. He signed the EMTALA transfer paperwork that gave us permission to look for placement. We sent out clinicals to 5 different places. [Hospital C] accepted him as a patient. The other 4 facilities declined. We ended up having to call out the police department because he became aggressive. The police officer waited while we were trying to find a place to transfer him. When our social worker went to inform him of his transfer to [Hospital C] he declined it. The police were present during this interaction. Once he declined that option, that is when the police took him into custody. We didn't tell the police to take him, they just took custody of him based on his behavior. The police were aware of how many hospitals had already declined this patient.

After reviewing the intake note, it looks like we knew he was being transferred to [Hospital B]. We did not direct the police officer to take the patient to [Hospital B]. I know we completed all the appropriate transfer paperwork and MOT for his [Hospital C] transfer, but I don't know if we did all of that for [Hospital B].

During an interview on 08/26/2024 at 9:10 AM, Personnel #5 stated the night [Patient #1] came in he was offered a transfer. He was very agitated and aggressive, so the night supervisor was helping me. The police had already been called. He had threatened staff physically and verbally. We explained to the police that we were trying to get [Patient #1] transferred and he was ok with that at that time. [Hospital C] accepted him and when we went to take him the disposition form, he stated he did not want to go to [Hospital C]. The police made the decision to take him to [Hospital B].

I knew the patient was being transferred to [Hospital B] and I documented that [Patient #1] was being transferred to [Hospital B] by the [Police Department]. We did not call report to [Hospital B] or complete any paperwork for [Hospital B] because we did not facilitate that transfer. The police facilitated that transfer. It was more that the patient refused our treatment and refused the transfer we had arranged so the police made the decision to take him to [Hospital B].

Police Department Report completed 07/24/2024 at 2:32 PM by Officer reflected the following, " ...Upon arrival at 2252, employee's informed that the MAP [mental application patient] (Patient #1) was inside the locked clinic doors. I spoke to the staff inside the locked clinic doors, and immediately, MAP appeared agitated and stating that he was not going to talk to the police. The clinic staff informed me that MAP had gone in for an evaluation, and after finishing he would kill them and kill himself. Once the MAP was upset and yelled, the employees said that they could not take him which agitated the MAP due to him wanting/needing assistance.

I spoke to MAP who I remembered from a past call at the same location. MAP began calming down during the situation and was able to talk to me about what was going on. MAP mentioned wanting to get assistance and getting denied.

[Hospital A] staff mentioned that they had a transfer for the MAP in process and had contacted transport. I was able to be direct and inform MAP about staff waiting to see which hospital would accept. MAP was open to going anywhere needed except a couple of hospitals.

[Hospital A] appeared to list the MAP as 'aggressive' which caused the MAP to be denied all hospitals except one. Only one hospital accepted MAP, which he decided to deny as well. MAP refused the hospital due to getting previous care at the location and 'nothing happening'. MAP asked to be taken to [Hospital B] although he also has 'bad experiences' at [Hospital B].

I was able to speak to MAP and let him know that in order to make sure that he was safe, he could be transported to [Hospital B]. MAP was receptive to take a ride with me and was transported to [Hospital B] ...in order to keep him from harming himself, anyone else, and get regulated back on his medications. MAP was released to [Hospital B] staff without any incident ..."

Hospital B History of Presenting Illness completed on 7/24/2024 at 2:20 AM reflected the following, "[Patient #1] ...presents under Legal Status: DW-Detention Warrant due to concern about harm to self and harm to others. Per warrant: 'Told [Hospital A] staff that he wanted to kill them and then kill himself. Many diagnosis of Bipolar, depression, anxiety, autism, sensory overload.' Interview Details: Patient appears agitated and wanted to sleep instead of talking to provider. After a few attempts patient agreed to talk. Pt states that he came back from Kentucky because it did not work out over there. He came there thinking that the shelter is better but it wasn't. He came back and wanted to go to [Hospital A] to check in for a few weeks. They did not let him. When asked about his reason for going there, he states that he just want a break from the street. He wants to calm down in the inpatient unit. He likes [Hospital A] facility so he went there. However, they told him that they are out of rooms. They wanted to send him to another hospital. He was upset because he just wants the room in [Hospital A]. They called the police on him to take him to [Hospital B]. He denies SI/HI [homicidal ideation]/AVH [auditory verbal hallucinations] ... ASSESSMENT/PLAN: Patient is not a harm to himself or others. Patient is autistic and his emotion is not well regulated. He tends to get upset and threatening when he does not get what he wants. He is contracting for safety at this time. He does not meet criteria for inpatient at this time: discharge to shelter in AM ..."