HospitalInspections.org

A. Based on review of medical records, the Emergency Room Register (ERR), and staff interview, it was determined the Hospital failed to ensure an appropriate transfer process was followed, refer to A2409.

A. Based on a review of Hospital policy, medical record review, Emergency Room Register (ERR), medical record review from receiving hospital, and staff interview, it was determined that in 1 of 10(Pt #1) medical records reviewed in which the patient was transferred, the Hospital failed to ensure transferring patients had been informed of the risks and benefits associated with the transfer and contacted a receiving hospital for an acceptable transfer from the Emergency Department (ED).

Findings include:

1. The Hospital policy titled "Transfer policy" (revised 8/03) was reviewed on 4/18/12. It indicated "Background: "Transfer" occurs any time a patient is discharged to another medical facility...Patient condition is documented as Emergent/Urgent or Non-Emergent. Emergent conditions are identified as stable or unstable..."

2. The medical record of Pt. #1 was reviewed on 4/18/12. Documentation indicated Pt. #1 was admitted to the ED on 4/11/12 at 1830 with Chief Complaint of Suicide Attempt. Documentation indicated Pt. #1 received a Medical Screening Exam (MSE) at 1835. The physician ordered laboratory testing and a mental health exam. Documentation indicated a Mental Health Counselor arrived at 2015 and completed an evaluation. Documentation indicated that Pt. #1's mother had contacted the Receiving Hospital and was going to drive Pt. #1 there herself. Mental Health Counselor Documentation indicated Pt. #1 "advised that SI (Suicidal Ideation) still present, no intent with plan at discharge, advised would go with mother without a fight." Documentation indicated the physician discharged Pt. #1 at 2220 with written discharge instructions. Documentation indicated Pt. #1 "Transferred to psych facility to care of mom. She will take to (Receiving Hospital)." There was no documentation of Pt. #1's condition or stability, or that the receiving hospital was contacted and accepted the transfer of pt.#1.

3. The Hospital ERR was reviewed on 4/18/12. Documentation indicated Pt. #1 was logged in on 4/11/12 at 1830 via ambulance with Chief Complaint of "Suicide Attempt" and was discharged with mother at 2220 to go to Receiving Hospital.

4. During an interview with the ED Nurse Manager and Chief Nursing Officer (CNO) on 4/18/12 at 1:00 PM, it was reported that Pt. #1 was discharged on 4/11/12 to mother. Pt. #1 was going to Receiving Hospital for psychiatric care and treatment. The Nurse Manager and CNO both confirmed that there are no ambulances to transport voluntary or involuntary patients for psychiatric care. Both confirmed mother had called the Receiving Hospital herself and talked with the receiving hospital about accepting Pt.#1. The Nurse Manager and CNO both confirmed there was no transfer forms completed because Pt. #1 was discharged.

5. During a telephone interview with the ED physician conducted on 4/19/12 at 1:45 PM, the physician recalled Pt. #1 presenting to the ED with suicidal ideation. The physician stated that after the exam and evaluation by the Counselor it was determined Pt. #1 was not a suicidal risk and could be transported by her mother to the Receiving Hospital. The physician stated that is the reason he discharged Pt. #1 instead of transferring. The physician stated he would never discharge an unstable patient.

6. The medical record of the Receiving Hospital was reviewed on 4/19/12. Pt. #1 arrived at the ED on 4/12/12 at 0145 with Chief Complaint of Suicide Attempt. Documentation indicated Pt.#1 was accompanied by parent. Documentation indicated Pt. #1 was at transferring Hospital and was told by that Hospital to "come here to get admitted and that they sent the papers ahead". Documentation indicated Pt. #1 was admitted for inpatient care to the Receiving Hospital at 0403 in fair condition with diagnoses of Suicidal Ideation, Suicide Attempt, and History of Bipolar. The medical record did not have any transferring records from the transferring hospital.

7. The above findings were confirmed by the ED Nurse manager and Chief Nursing Officer on 4/18/12 at 3:00 PM