HospitalInspections.org

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Based on Medical Record review, document review, and staff interview, in five (5) out of six (6) Medical Records, the CPEP (Comprehensive Psychiatric Emergency Program) Staff did not implement the facility's Policy and appropriately document an accepting Attending Physician for patients transferred from the Psychiatric Emergency Room to an Inpatient Psychiatric Facility.

This lack of documentation resulted in patients not having a documented responsible Physician when they were being transferred to another inpatient facility.

Findings:

The facility's Policy and Procedure titled "Emergency Department: Inter-Hospital Transfers" last revised 10/01/13, stated the following: "(B.) (2) All patients to be transferred must have an identified sending and accepting Attending Physician and facility" and "This must be documented in the Medical Record."

The facility's Policy and Procedure titled "Mental Health Services: Transfer To / From Another OMH (NY State Office of Mental Health) Licensed Facility", last revised 03/06/15, states the following: "The sending facility completes Form A (Request for Order of Transfer) and Form B (Information Checklist) or the equivalent."

Patient #2's Medical Record identified that the patient was brought in by Police on 03/12/16 due to his mother reporting that the patient was having irrational behavior and altered mental status. The Psychiatry Progress Note on 03/13/16 documented that "The patient is psychotic, violent, unable to avoid any danger to self or others and would benefit from inpatient hospitalization".

The Care Management Discharge Progress Note on 03/13/16 documented "Patient to be admitted via DOCS (Director of Community Services)" and "Plan: DOCS admission back to South Oak called for preauthorization." The Progress Notes then documented on 03/14/16 "Discharged to Psychiatric Unit...South Oaks Hospital".

The Medical Record contains a completed "Involuntary Admission Certification" and a completed "Transportation Provider Order Sheet". However, the "Comprehensive Psychiatric Emergency Program Transport Log" Form was blank regarding an accepting Physician's name and phone number. There is no documentation in the Medical Record indicating that a Physician accepted the patient for transfer.

During an interview on 03/14/16 at 11:30AM Staff B stated that the Social Worker reaches out to the Insurance Company for authorization and to the facilities to get a bed. Clinical (information) is then sent to the Admissions Office for review. The CPEP Physician does not call the facility. Some facilities have a specific Physician who accepts the patient and the Physician will call back or it can be the Intake Person at South Oaks and Brunswick. It depends on the facility.

The same incomplete (blank) "Comprehensive Psychiatric Emergency Program Transport Log" Forms regarding an accepting Physician's name and phone number were also found in the Medical Records for Patients #1, #3, #4 and #12.