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Based on record review and interview, the hospital failed to ensure a discharge planning evaluation was performed for 1 (#20) of 4 sampled patients reviewed for discharge planning out of a total sample of 24.
Findings:

Review of the hospital policy titled, "Case Management Plan for Discharge Planning Policy", provided by S1Director of Quality as the hospital's policy for discharge planning, revealed the following: The discharge plan will be developed by nursing for those patients without identified discharge planning needs. When changes are noted in a patient's condition that now necessitate interventions for the discharge plan, the Case Manager/Social Worker will be notified of the changes. The Case Manager/Social Worker will develop the discharge plan, setting expectations for estimated length of stay, goals, anticipated disposition, etc. and arrange for the initial implementation of the discharge plan.

Patient #20
Review of the medical record for Patient #20 revealed the patient arrived at the hospital's emergency department (ED) on 09/19/16 at 8:12 p.m. per ambulance after being found unresponsive. Review of the ED physician's notes revealed an empty bottle of Tylenol #4 was found next to the patient. The notes further revealed that the patient was intubated and placed on a ventilator and admitted to the intensive care unit on 09/19/16.Review of the record revealed a Discharge Planning Screening/Assessment dated 09/20/16. Review of this assessment revealed "patient in ICU on vent, visited with his aunts.....they state patient was living with his girlfriend". The expected discharge plan was documented as "unknown".Further review of the record revealed the patient was PEC'd (Physicians Emergency Certificate) on 09/24/16 at 5:45 p.m. Review of the PEC revealed the physician documented that the patient was awake, alert/oriented/not happy to be alive and currently suicidal.The record revealed the patient was transferred from the ICU to the medical floor on 09/25/16 at 5:00 p.m. There was no further documentation of any discharge planning in the patient's record until 09/26/16 at 9:50 a.m. Review of the discharge planning note written by the case manager revealed the patient stated that he was going to be sent somewhere else for help. The note further stated "will follow up with social services plan". Review of the patient's record revealed no documented social services discharge plan. The next (and final) discharge planning note in the patient's record was dated 09/27/16 at 1:15 p.m. written by S3Case Manager. The note revealed "Called and faxed to a lot of psych facility. I have not been able to find a bed for patient. Called S6Physician/Coroner office....pts PEC is up at 5:00, called S12Physician had to leave message, plan will be for him to call and follow up with me regarding patient status". There was no documented evidence in the record of what psychiatric hospitals S3Case Manager had contacted and there was no documented discharge plan in the record. The record revealed a physician's order dated 09/27/16 to discharge the patient home. Review of the nurses note dated 09/27/16 at 2:45 p.m. revealed that the patient was discharged home with immediate follow-up in S6Physician/Coroner's office. Discharge paperwork not completed or signed at this time. Discharged in stable condition via wheelchair with police escort. On 11/01/16 at 2:00 p.m., S3Case Manager and S5Director of Case Management reviewed patient #20's medical record and confirmed that there was no documented evidence that a discharge plan had been developed for the patient. They further confirmed that there was no documentation of the psychiatric hospitals that had been contacted for possible transfer of the patient. Further interview with the above staff revealed that the physician wrote an order to discharge the patient home, although the patient was transferred to S6Physician/Coroner's office for a Coroners Emergency Certificate (CEC). They stated that this was usual practice for the hospital to discharge psychiatric patients "home", but immediately transfer the patients to the coroners office for a CEC, if the case managers are unable to locate a psychiatric bed for the patient.

EMTALA Complaint #LA00044219

Based on record reviews and interviews, the hospital failed to meet the requirement of §489.24 as evidenced by:

Based on record review and interviews, Hospital A failed to implement an appropriate transfer for 2 of 20 patients (#1, #24) who presented to the Emergency Department with an emergent psychiatric condition to a hospital that offered in-patient psychiatric treatment. This was evidenced by the failure to:

1) Ensure there was a receiving hospital that agreed to accept patients #1 and #24;

2) Provide the medical record information of the treatment patients #1 and #24 receive while in the Emergency Department at Hospital A.

Based on record review and interviews, Hospital A failed to implement an appropriate transfer for 2 of 20 patients (#1, #24) who presented to the Emergency Department with an emergent psychiatric condition to a hospital that offered in-patient psychiatric treatment. This was evidenced by the failure to:

1) Ensure there was a receiving hospital that agreed to accept patients #1 and #24;

2) Provide the medical record information of the treatment patients #1 and #24 receive while in the Emergency Department at Hospital A.

Findings:

1) Ensure there was a receiving hospital that agreed to accept patients #1 and #24;

Patient #1
Review of patient #1's Emergency Department (ED) Record revealed the patient presented to the ED on 06/10/16 at 5:55 p.m. with the chief complaint of major depression with suicidal ideation; shared psychotic disorder. Patient stated he felt suicidal and tried to cut his wrist and face with a beer cap. On 06/10/16 at 5:58 p.m., the ED physician implemented a Physician Emergency Certificate. While in the ED laboratory tests were drawn, medications administered, and the superficial wounds were treated. A sitter was assigned to patient #1 to provide 1:1 observation. Review of the Case Manager notes revealed that on 06/10/16 beginning at 8:00 p.m. and again on 06/11/16 at 8:16 p.m., patient information was faxed to numerous hospitals that had psychiatric beds; however, these attempts for placement were unsuccessful.

Review of the patient's disposition revealed on 06/13/16 at 11:36 a.m. the patient was to be discharged to an "Extended Care Facility" for "Major Depression with Suicidal Ideation, Shared psychotic disorder." and was listed as "stable" upon release. Further review of the disposition revealed the patient was taken to S6Physician/Coroner's office by Sheriff Deputies for evaluation and a Coroner Emergency Certificate. The patients psychiatric condition was identified as chronic and the symptoms unchanged.

Interview on 11/03/16 at 10:00 a.m. with S8Sheriff Deputy revealed the Sheriff Deputies were instructed by S6Physician/Coroner to transfer patient #1 to the Emergency Department at Hospital B for the same emergent psychiatric condition he had presented to Hospital A with on 06/10/16. Patient #1 was discharged from the Emergency Department (ED) of Hospital A, transferred by Sheriff Deputies from the hospital's ED to S6Physician/Coroner's office for a Coroners Emergency Certificate, then transferred by the Deputies to the Emergency Department at Hospital B for in-patient psychiatric treatment.

Review of the Emergency Department Record from Hospital B revealed patient #1 presented to their ED on 06/13/16 at 12:57 p.m. accompanied by police for suicidal behavior, and the patient was placed on a Physician Emergency Certificate (PEC). The Sheriff Deputies reported they had received a call from a Medical Staff Member in the ED at Hospital A to take patient #1 to S6Physician/Coroner's office for a psychiatric evaluation and a Coroners Emergency Certificate (CEC), then instructed by the Coroner to transport patient #1 to the ED at Hospital B.

Interview on 11/01/16 at 2:40 p.m. with S7Physician/Emergency Department revealed when asked about psychiatric patients being transferred to S6Physician/Coroner's office, he replied when the ED had a psychiatric patient and they cannot find in-patient placement, this was the only way to get the patient transferred out of the ED and admitted to a hospital who had in-patient psychiatric beds.

Interview on 11/01/16 at 10:00 a.m. with S4RN/Case Manager revealed when asked about patient #1 being sent to the office of S6Physician/Coroner in order for a CEC to be completed, she replied S6Physician/Coroner had a busy private practice and since he could not leave his office and come to the Hospital ED, they would send the patient to him, accompanied by the Sheriff Deputies, for the CEC. S6Physician/Coroner would then instruct the deputies to take the psychiatric patient usually to the Emergency Department of Hospital B. When asked if the Coroner ever came to the hospital to do a CEC, S4RN replied "usually not" Patient #24
Review of patient #24's ED record revealed the patient presented on 10/19/16 at 5:57 a.m. with the chief complaint of eccentric manic behavior, word salad, flight of ideas, and auditory hallucinations. The patient also had a past history of schizophrenia. The ED physician completed a Physician Emergency Certificate on 10/19/16 at 6:20 a.m. Laboratory test and medication administration were provided and a sitter was placed with the patient for 1:1 observation. During patient #24's stay in the ED, documentation revealed numerous psychiatric hospitals were contacted in an attempt to transfer the patient for in-patient psychiatric treatment; however, acceptance was unsuccessful.

A form titled Discharge Instructions revealed the patient was to follow-up with her primary physician upon discharge for "Continuance of care". Review of the Discharge Assessment dated 10/21/16 at 4:23 p.m. revealed S4RN/Case Manager documented "Unsuccessful placement for patient, PEC expires 10/22/16 at 5:00 a.m. Discharge plan: to d/c (discharge) home with spouse and follow up outpatient with PCP (Primary Care Physician) or psychiatrist." On 10/22/16 at 9:50 a.m. the Registered Nurse documented the patient was discharged to home ambulatory.

Interview on 11/02/16 at 3:00 p.m. with S4RN/Case Manager revealed that on 10/22/16, patient #24 had been discharged from the ED but no responsible party could be contacted in order to release the patient. S6Physician/Coroner was making hospital rounds and afterwards came to the ED and implemented a Coroner Emergency Certificate on patient #24 even though she had been discharged. The patient was then transferred to another acute care hospital by Sheriff Deputies for in-patient psychiatric care. When asked why the patient was discharged from the ED, S6RN/Case Manager replied the PEC had expired and they could no longer hold the patient.

Interview on 11/02/16 at 3:30 p.m. with S2RN/Emergency Department Nursing Director revealed it was set up with S6Physician/Coroner to see patient #24 the next morning for a CEC and admission to a psychiatric facility. The patient had been discharged from the ED on 10/22/16 and was still manic but not a threat to herself or others. S2RN further added even though the patient was discharged she was allowed to sleep in an ED bed pending release to a responsible party. When asked about the disposition of patient #24 after S6Physician/Coroner implemented the CEC, S7RN replied S6Physician/Coroner would determine what hospital the Deputies were to transfer the patient.

Interview on 11/03/16 at 10:00 a.m. with S8Sheriff Deputy revealed when asked about the process of transferring psychiatric patients from the Emergency Department of Hospital A to S6Physician/Coroners office, the Deputy stated they would get a call from the dispatcher directing them to go Hospital A's ED to pick a patient up and take them to S6Physician/Coroners office. They would enter a side door with the psychiatric patient, S6Physician/Coroner would implement a CEC, then direct the Deputies where to take the patient, which was usually the Emergency Department at Hospital B.

2) Provide the medical record information of the treatment patients #1 and #24 received while in the Emergency Department at Hospital A;

Patient #1
Review of patient #1's ED record from Hospital A revealed on 06/13/16, patient #1 was released to the Sheriff Deputies and they were instructed to take the patient to S6Physician/Coroner's office for a Coroner Emergency Certificate. The Sheriff Deputies were then told by the Coroner to transfer patient #1 to the ED at Hospital B.

Review of the ED record from Hospital B revealed on 06/13/16 at 1:28 p.m. the Case Manager obtained an "Authorization for release of information" which was signed by the patient and the form faxed to Hospital A in order to obtain the medical records of the care rendered to the patient from 06/10/16 to 06/13/16 while in the Emergency Department.

Patient #24
Review of patient #24's ED record from Hospital A revealed on 10/19/16 the patient presented to the ED with manic behaviors. During the ED visit from 10/19/16 to 10/22/16, a PEC was implemented, medications for the behaviors administered, and 1:1 observations provided. On 10/22/16, the Registered Nurse documented the patient was discharged ambulatory from the ED; however, this did not occur. Interview on 11/02/16 at 3:30 p.m. with S2RN/Emergency Department Nursing Director revealed it was set up with S6Physician/Coroner to see patient #24 the next morning for a CEC and admission to a psychiatric facility. The patient had been discharged from the ED on 10/22/16 and was still manic but not a threat to herself or others. S2RN further added even though the patient was discharged she was allowed to sleep in an ED bed pending release to a responsible party. When asked about the disposition of patient #24 after S6Physician/Coroner implemented the CEC, S7RN replied S6Physician/Coroner would determine what hospital the Deputies were to transfer the patient.

Further review of patient #24's ED record revealed even though the patient had been discharged from the ED, she was still in an ED bed waiting for release to a responsible party. When S6Physician/Coroner examined the patient on the morning of 10/22/16, a CEC was implemented; however, there failed to be documentation of where the patient was transferred to and if any medical record information accompanied the patient related to the treatment rendered in the ED from 10/19/16 to 10/22/16.

Interview with S8Sheriff Deputy on 11/03/16 at 10:00 a.m. revealed when asked if any medical record would accompany the patient when they had to transfer them from the ED at Hospital A to the Coroners office, he replied they usually just had the CEC.