HospitalInspections.org

Based on medical record review, policy review, and staff interview, the hospital failed to make appropriate notification to the receiving hospital and failed to send the medical record related to the emergency condition which the individual had presented with that were available at the time of the transfer (A2409).

Based on medical record review, policy review, and staff interview, the hospital failed to make appropriate notification to the receiving hospital and failed to send the medical record related to the emergency condition which the individual had presented with that were available at the time of the transfer for one of 19 patient medical records reviewed (Patient #1).

Census: 24

Review of the facility's Transfer and Discharge Criteria/Process-Policy Number: 5.01 revealed "If the patient is assessed as having needs that are not able to be met at McCullough-Hyde Memorial Hospital, external transfer will be arranged".

On 06/18/18, a review of the facility's 06/11/18 emergency department (ED) log revealed three patients transferred out to other facilities. One of those patients, Patient #1, arrived in the ED on 06/11/18 at 5:22 PM with a chief complaint of suicidal. The patient reported suicidal thoughts, relapsed with heroin and methamphetamine that day and the previous night. Patient #1 was stressed about new criminal charges and was expected to return to prison.

Review of the ED Course & Medical Decision Making revealed Patient #1 did physically "shop" one of the staff members and the staff person suffered a minor injury. Security was called and Geodon (antipsychotic) 10 milligrams intramusculary was administered. The patient was placed on a 72 hour hold and placed in police custody. The patient's Departure Condition at 6:40 PM on 06/11/18 revealed the patient was stable and ambulatory. The patient left the ED at 6:53 PM.

Review of the corresponding nurse notes revealed the patient was verbally abusive and threatening violence to self and staff. The patient was upset at the facility and requested to be transferred to a psych facility. Police were called when the patient made aggressive motions toward staff. The patient was talked into allowing the staff RN to administer a shot of Geodon. The physician signed a psychiatric hold along with the police, and the patient was released to the police in hand cuffs to be transferred to another hospital located in Hamilton, Ohio.

The medical record lacked documentation report was given to the receiving facility as to the patient's condition and reason for transfer. There was no evidence the patient's medical record was sent to the receiving hospital. The patient was given discharge instructions which she signed that she understood.

An interview with Staff A and Staff C on 06/19/18 at 10:15 AM revealed a nurse to nurse report was to be completed and documented in the medical record for patients transferred out, as a standard practice.

Further interview with Staff A on 06/19/18 at 11:30 AM confirmed no report was called to the receiving facility for Patient #1. The patient arrived at the facility on 06/11/18 with a primary diagnosis of suicidal and the patient was transferred to another facility without report called to the receiving facility.