HospitalInspections.org

Based on interview and document review, the facility failed to transfer and communicate pertinent medical information to another Hospital for one patient who was Baker Acted (Patient #1).


The findings include:


An interview was conducted with the Complainant on 4/25/2018 at 8:45 AM. The Complainant stated that the facility failed to let them know that they were sending Patient #1, who was Baker Acted on 2/18/18 at 22:59. The Complainant stated that the Patient arrived in handcuffs with Police transport with no report and no medical information. They stated that there was only the facility generated Baker Act Form and the sending facility did not provide an appropriate transfer as required.


An interview was conducted with Employee E, RN on 4/26/2018 at 11:35 AM. She stated that, "It is usually the Health Unit Coordinator who speaks to the Transfer Center and/or the Psychiatric Screener will initiate the call. The RN will also provide a report." Employee E, RN stated that if it was her role in transferring the patient, she could look in the computer to see if someone gave report to the receiving facility. The Case Management and Behavioral Health areas would also be reflected if the information had been scanned at the time. "Ultimately, the Screener sends the report to the receiving facility; the nurse calls and talks to the nurse at the receiving facility, then a transport is arranged with Law Enforcement to make the transfer. There is a nurse-to-nurse report to transfer. A report is documented in "Special Charting;" that report would be provided to the receiving facility. This would be in transfer paperwork who they spoke to at the receiving facility. The transferring and reporting nurse would be responsible for the transfer paperwork. The only thing prepared initially is the actual Baker Act. There is a Unit Secretary 24/7. Sometimes two Secretaries to help with this".


An interview was conducted with Employee C, Emergency Department Director on 4/26/2018 at 3:15 PM, and she confirmed that there was no Certification for Transfer for Patient #1; no Transfer Form, "Because the patient was not transferred." Employee B, RN documented that Police intervened and put Patient #1 in cuffs. Employee B, RN said that the patient was extremely violent; police had him under administrative handcuffs. All of a sudden, he (Patient #1) was gone; the police just took him. The facility stated that they did not know that the police were leaving with the patient, and the Risk Manager confirmed that the local Police Department just comes and takes people against the facility policy and procedures.


An interview was conducted with Employee A, RN on 4/26/2018 at 3:37 PM, who confirmed that she was the nurse caring for Patient #1 at the time of his visit to the Emergency Department. She confirmed that the case was close to the end of her shift and she recalled that the patient arrived because he was found wandering around a community not making any sense. While she was in another patient's room, when Patient #1 found out he was being placed under a Baker Act, he lost it. She confirmed that she did not provide a report to the receiving facility and that she was not sure if the patient was medically cleared at the time. She stated that was the Screener's process who was making a determination to send him somewhere, and she did not know where he ended up going. She stated that she did not know if the evaluation was completed and that she did not know the outcome for Patient #1. She expected he would be transferred to a Psychiatric facility.


An interview was conducted with Employee D, MD on 4/26/2018 at 3:55 PM. He stated that he did recall the events related to Patient #1. He did not recall providing anything more than a completed Baker Act Form and took no additional actions once the Baker Act Form was initiated, allowing local Police to remove the patient from the facility Emergency Department without a completed Transfer/Discharge Order. He stated, "When the Police had arrested the patient, and they said that they were taking him away, when a Police Officer says that to me, it is pretty much written in stone."