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Based on observation, interview, and record review, the facility failed to ensure signage specifying the rights of individuals with emergency medical conditions (EMCs), and the facility's participation in the Medicaid (government sponsored health insurance) program, were posted in the two outdoor tents of the Emergency Treatment Services (ETS - emergency department for psychiatric services) triage (process of quickly examining patients to prioritize care) and waiting areas.

This failure resulted in the potential for patients presenting to ETS to not be aware of their rights to receive medical treatment for an EMC.

Findings:

During a concurrent observation and interview, on April 4, 2022, at 2 p.m., with the Executive Director (EXD), a tour of the ETS outdoor area was conducted.

Two tents, one larger than the other, were observed set up in the parking lot outside of the ETS building entrance.

In the smaller tent, three adults, one child, and an infant in a stroller were observed sitting in chairs.

In the larger tent, three staff members were observed with medical supplies and equipment.

There was no signage specifying the rights of individuals with EMCs or the facility's participation in the Medicaid program posted inside or outside either of the two tents.

The EXD stated the smaller tent was used as a waiting area for individuals that presented to the facility by either walking in voluntarily, accompanied by law enforcement, or brought by ambulance for evaluation.

The EXD stated the larger tent was used as the facility's triage area, with nursing staff providing assessments and laboratory testing.

The EXD continued to state providers would be notified once a patient had arrived and was triaged. The provider would then evaluate patients in the triage tent after notification.

The EXD stated the tents were erected in early 2020 at the start of the Covid-19 (a highly contagious respiratory disease) pandemic (outbreak), and have been used as waiting and triage areas continuously for the past two years.

The EXD stated there were no signs posted in or near the tents that specified the rights of individuals with EMCs or the facility's participation in the Medicaid program.

The EXD stated this was an oversight and the signs should have been posted.

During a review of the facility's policy and procedure (P&P) titled, "Screening, stabilizing treatment and transfer of patients with Emergency Medical Conditions," dated December 9, 2020, the P&P indicated, "...The Hospital will post signage conspicuously in lobbies, waiting rooms, admitting areas and treatment rooms where examination and treatment occurs in the form required by law that specifies the rights of individuals to examination and treatment for emergency medical conditions and (that) the Hospital participates in the Medi-Cal program..."

Based on interview and record review, Facility 1 failed, for one of 34 sampled patients (Patient 1), to ensure within the capabilities of the staff and resources available at Facility 1's ETS (Emergency Treatment Services - emergency department [ED] for psychiatric services), that the patient was stabilized and free from harm or danger to self (DTS) prior to discharge or transfer.

This failure resulted in Patient 1's unsafe discharge and an inappropriate transfer from Facility 1, with the potential for injury or death to Patient 1.

Findings:

Patient 1's record from Facility 1 was reviewed on April 4, 2022. Patient 1 arrived to Facility 1's ETS on March 2, 2022, at 7:46 a.m., and was discharged the same day at 9:18 a.m. (approximately one hour and 30 minutes later).

Facility 1's Registered Nurse (RN) "ED Notes," dated March 2, 2022, at 7:50 a.m., indicated, "...Per mother patient (Patient 1) has been emotional and upset and threatened to kill herself..."

Patient 1's "ED Provider Notes," from Facility 1, dated March 2, 2022, at 8:46 a.m., indicated, "...14 y/o (year old)...VOL (voluntary - admitted by choice)...Father says pt (Patient 1) says she will kill herself. He wants her to be admitted now to a hospital. When asked about her intent to commit suicide, pt says 'Well, I can't say.'...They have Blue Cross insurance...Dx (diagnosis): Depression (serious medical illness that negatively affects how you feel, the way you think, and how you act) with Suicidal Ideation (thoughts of killing yourself)...Plan: Mother will take pt to (Facility 2's) ED, 15 miles away, and pt agrees to cooperate with this plan..."

Patient 1's "Disposition," from Facility 1, dated March 2, 2022, at 8:44 a.m., indicated, "Disposition: Discharge...Condition...Fair...Parent will take her to (Facility 2's) ED for admission..."

There was no documentation by the provider that Patient 1 was provided further care or stabilization prior to transfer or discharge from Facility 1.

There was no documentation indicating Patient 1 was stable for discharge. In addition, the record did not reflect documentation of an appropriate transfer, including consent, an acceptance by the receiving facility's physician, or that the determination for a safe mode of travel, such as an ambulance transfer, was arranged.

During an interview on April 4, 2022, at 3:05 p.m., conducted with Physician 1 (from Facility 1), Physician 1 stated in order to prevent the transfer or discharge of an unstable patient, the patient would need to be evaluated by a physician and deemed to be stable.

During a telephone interview on April 5, 2022, at 10:25 a.m., conducted with Physician 2 (from Facility 1), Physician 2 stated the facility's ETS has the resources in order to stabilize and/or admit patients that are in need of psychiatric treatment for an EMC, including adolescents and children. Physician 2 further stated if a patient is in need of stabilization for a DTS or DTO (danger to others), the facility should observe and manage the patient by referring to the facility's in-house specialists.

During a telephone interview on April 5, 2022, at 3:05 p.m., with the Chief of Psychiatry (COP) from Facility 1, the COP stated if an adolescent or child arrived to the facility on a voluntary status and was assessed as a high risk, including DTS, the patient could be admitted to the facility's ETS for observation and stabilization until a decision is made for either inpatient admission, or a safe discharge or transfer.

During a telephone interview on April 5, 2022, at 9:50 a.m., conducted with Patient 1's responsible party (RP 1), RP 1 stated Patient 1 was taken to Facility 1's ETS by RP 1 in the early morning of March 2, 2022, and wanted her to be admitted due to suicidal thoughts. RP 1 stated Patient 1 did not receive any services at ETS. RP 1 stated they were directed to take Patient 1 to a different hospital, Facility 2, because of their insurance.

Patient 1's record from Facility 2 was received and reviewed on April 5, 2022.

Patient 1's "ED Arrival Information," from Facility 2, indicated Patient 1 arrived at Facility 2's ED on March 2, 2022, at 9:57 a.m. (39 minutes after discharge from Facility 1's ETS), with the chief complaint of "...Referred to (Facility 2) by (Facility 1's) Emergency Services..."

Facility 2's "ED Arrival Notes," for Patient 1, dated March 2, 2022, at 11:16 a.m., indicated, "...Note, she was seen at (Facility 1's) ETS prior to presentation to (Facility 2) and diagnosed with depression with suicidal ideation. They advised parent to present to (Facility 2's) ED..."

The "Psychiatric Consult Service Evaluation," from Facility 2, dated March 2, 2022, at 4:50 p.m., indicated, "...(Patient 1) endorses having suicidal ideations with no specific plan, and has hurt herself by scratching and cutting. She has red scratch marks on her bilateral (both) legs and her stomach...This morning, patient called mom at 6:30 am and she was 'hysterical, saying that she was going to kill herself'...This episode became more severe, and parents are 'afraid that she'll actually do something'...At this time, parents believe it would be unsafe for their daughter to return home...Assessment...At this time, patient is unable to state how she would prevent herself from acting on her suicidal thoughts if discharged, and would benefit from inpatient psychiatric care...Psychiatric Diagnosis: MDD (major depressive disorder)...Disposition: (Patient 1) meets criteria for inpatient psychiatric hospitalization...5150 (72-hour legal, involuntary hold placed on individuals needing psychiatric treatment for a DTS, danger to others [DTO], or gravely disabled [GD]) placed...at 17:05 (5:05 p.m.) on 3/2/2022 (March 2, 2022) for DTS and GD...1:1 sitter (one staff to monitor one patient continuously) for safety until placement is found..."

During a review of the Facility 1's policy and procedure (P&P) titled, "Screening, stabilizing treatment and transfer of patients with Emergency Medical Conditions," dated December 9, 2020, the P&P indicated, "...Emergency Medical Condition means...a medical condition manifesting itself by acute symptoms of sufficient severity (including...psychiatric disturbances...) such that the absence of immediate medical attention could reasonably be expected to result in: Placing the health of the individual...in serious jeopardy...Stabilized means, with respect to an emergency medical condition, either...That a patient's medical condition has been resolved; or...That no material deterioration of the patient's condition is likely within reasonable medical probability, to result from or occur during a transfer to another Hospital...For the purpose of discharging an individual with psychiatric condition(s), the individual is considered to be stable for discharge when he/she is no longer a threat to himself/herself or to others...Transfer means the movement of a patient to another acute care hospital at the direction of a physician or the Hospital's medical staff and with the agreement of the hospital to which the patient is being transferred..."

Based on interview and record review, Facility 1 failed, for one of 34 sampled patients (Patient 1), to ensure the requirements of an appropriate transfer, including the provision of medical treatment within Facility 1's capabilities, a physician's certification that the medical benefits outweighed the risks to the individual from the transfer, the legal representative consented to the transfer, acceptance by the receiving facility's physician, and the determination of a safe mode of transfer was completed when Patient 1 was sent from the Facility 1's Emergency Treatment Services (ETS - emergency department [ED] for psychiatric services), and were directed to seek care at Facility 2's ED.

This failure resulted in Patient 1 to be inappropriately transferred to an alternate acute care facility (Facility 2), which potentially did not have the capability or capacity to care for Patient 1, possibly resulting in harm or death to Patient 1.

Findings:

Patient 1's record from Facility 1 was reviewed on April 4, 2022. Patient 1 arrived to Facility 1's ETS on March 2, 2022, at 7:46 a.m., and was discharged the same day at 9:18 a.m. (approximately one hour and 30 minutes later).

Facility 1's Registered Nurse "ED Notes," dated March 2, 2022, at 7:50 a.m., indicated, "...Per mother patient (Patient 1) has been emotional and upset and threatened to kill herself..."

Patient 1's "ED Provider Notes," from Facility 1, dated March 2, 2022, at 8:46 a.m., indicated, "...14 y/o (year old)...VOL (voluntary - admitted by choice)...Father says pt (Patient 1) says she will kill herself. He wants her to be admitted now to a hospital. When asked about her intent to commit suicide, pt says 'Well, I can't say.'...They have Blue Cross insurance...Dx (diagnosis): Depression (serious medical illness that negatively affects how you feel, the way you think, and how you act) with Suicidal Ideation (SI - thoughts of killing yourself)...Plan: Mother will take pt to (Facility 2's) ED, 15 miles away, and pt agrees to cooperate with this plan..."

Patient 1's "Disposition," from Facility 1, dated March 2, 2022, at 8:44 a.m., indicated, "Disposition: Discharge...Condition...Fair...Parent will take her to (Facility 2's) ED for admission..."

There was no documentation by the provider that Patient 1 was provided further care or stabilization prior to transfer or discharge from Facility 1.

There was no documentation indicating Patient 1 was stable for discharge. In addition, the record did not reflect documentation of an appropriate transfer, including consent, an acceptance by the receiving facility's physician, or that the determination for a safe mode of travel, such as an ambulance transfer, was arranged.

During an interview on April 4, 2022, at 3:05 p.m., conducted with Physician 1 (from Facility 1), Physician 1 stated in order to prevent the transfer or discharge of an unstable patient, the patient would need to be evaluated by a physician and deemed to be stable.

During a telephone interview on April 5, 2022, at 10:25 a.m., conducted with Physician 2 (from Facility 1), Physician 2 stated the facility's ETS has the resources in order to stabilize and/or admit patients that are in need of psychiatric treatment for an EMC, including adolescents and children. Physician 2 further stated if a patient is in need of stabilization for a DTS (danger to self) or DTO (danger to others), the facility should observe and manage the patient by referring to the facility's in-house specialists.

During a telephone interview on April 5, 2022, at 3:05 p.m., with the Chief of Psychiatry (COP) from Facility 1, the COP stated if an adolescent or child arrived to the facility on a voluntary status and was assessed as a high risk, including DTS, the patient could be admitted to the facility's ETS for observation and stabilization until a decision is made for either inpatient admission, or a safe discharge or transfer.

The COP stated if a patient needs to be transferred to an alternate facility, the expectation would be for the facility to contact and obtain acceptance from the receiving facility's physician.

The COP stated the risks and benefits need to be discussed and a consent obtained with the patient or legal representative prior to transfer.

The COP stated once a transfer is approved, the patient could be sent by ambulance or with parental transportation, depending on the situation and a determination by the physician of a safe mode of travel.

During an interview on April 5, 2022, at 2:30 p.m., conducted with Facility 1's Assistant Nurse Manager of ETS (ANME), the ANME stated transportation must be arranged for patients that are going to be transferred to another facility. The ANME stated if a family transported a patient with SI in a private car, instead of by ambulance, the patient could open the car door and slide out.

During a telephone interview on April 5, 2022, at 9:50 a.m., conducted with Patient 1's responsible party (RP 1), RP 1 stated Patient 1 was taken to Facility 1's ETS by RP 1 in the early morning of March 2, 2022, and wanted her to be admitted due to suicidal thoughts. RP 1 stated Patient 1 did not receive any services at Facility 1's ETS. RP 1 stated they were directed to take Patient 1 to a different hospital, Facility 2, because of their insurance.

Patient 1's record from Facility 2 was received and reviewed on April 5, 2022.

Patient 1's "ED Arrival Information," from Facility 2, indicated Patient 1 arrived at Facility 2's ED on March 2, 2022, at 9:57 a.m. (39 minutes after discharge from Facility 1's ETS), with the chief complaint of "...Referred to (Facility 2) by (Facility 1's) Emergency Services..."

Facility 2's "ED Arrival Notes," for Patient 1, dated March 2, 2022, at 11:16 a.m., indicated, "...Note, she was seen at (Facility 1's) ETS prior to presentation to (Facility 2) and diagnosed with depression with suicidal ideation. They advised parent to present to (Facility 2's) ED..."

The "Psychiatric Consult Service Evaluation," from Facility 2, dated March 2, 2022, at 4:50 p.m., indicated, "...(Patient 1) endorses having suicidal ideations with no specific plan, and has hurt herself by scratching and cutting. She has red scratch marks on her bilateral (both) legs and her stomach...This morning, patient called mom at 6:30 am and she was 'hysterical, saying that she was going to kill herself'...This episode became more severe, and parents are 'afraid that she'll actually do something'...At this time, parents believe it would be unsafe for their daughter to return home...Assessment...At this time, patient is unable to state how she would prevent herself from acting on her suicidal thoughts if discharged, and would benefit from inpatient psychiatric care...Psychiatric Diagnosis: MDD (major depressive disorder)...Disposition: (Patient 1) meets criteria for inpatient psychiatric hospitalization...5150 (72-hour legal, involuntary hold placed on individuals needing psychiatric treatment for a DTS, danger to others [DTO], or gravely disabled [GD]) placed...at 17:05 (5:05 p.m.) on 3/2/2022 (March 2, 2022) for DTS and GD...1:1 sitter (one staff to monitor one patient continuously) for safety until placement is found..."

During a review of Facility 1's policy and procedure (P&P) titled, "Screening, stabilizing treatment and transfer of patients with Emergency Medical Conditions," dated December 9, 2020, the P&P indicated, "...The Hospital will not transfer an individual with an unstabilized emergency medical condition unless either (a) the individual requests the transfer having been informed of the related risks or (b) a physician certifies that the medical benefits reasonably expected from the provision of treatment at the receiving facility outweigh the risks to the individual from the transfer...
Requirements for an Appropriate Transfer. An individual with an unstabilized emergency medical condition may be transferred only after:
i. The Hospital provides medical treatment within its capacity to minimize the risks to the individual's health...;
ii. The patient or legal representative on the patient's behalf has consented to the transfer;
iii. The medical record reflects the vital signs and condition of the individual at the time of the transfer;
iv. The receiving facility has available space and qualified personnel for treatment of the individual; and the receiving facility and receiving physician's agreement to accept the individual and provide appropriate medical treatment is documented in the patient's record;
v. A copy of all medical records available at the time of transfer related to the emergency medical condition, including (i) records related to the individual's emergency condition; (ii) the individual's informed written consent to transfer (iii) the physician certification...; and
vi. Proper personnel and equipment, as well as necessary and medically appropriate life-support measures during the transfer has been obtained. The transferring physician is responsible to determine whether an individual is stabilized and the mode of transportation, equipment, and personnel required for transfer..."