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Based on interview and record review the facility failed to ensure 1 of 1 patients with an unresolved psychiatric emergency medical condition (EMC) received an appropriate transfer( Patient #8). The facility failed to ensure transfer paperwork was complete and accurate on patients (Patient #s' 8, 12, 26, 27, 28, 29, 30, and 31).
This deficient practice had the likelihood to cause harm in all psychiatric patients presenting to the Emergency Department (ED).
Refer to tag A 2409 for additional information.

Based on interview and record review the facility failed to ensure 1 of 1 patients with an unresolved psychiatric emergency medical condition (EMC) received an appropriate transfer ( Patient #8). The facility failed to ensure transfer paperwork was complete and accurate on patients (Patient #s' 8, 12, 26, 27, 28, 29,30, and 31).
This deficient practice had the likelihood to cause harm in all psychiatric patients presenting to the Emergency Department (ED).
Findings include:

Review of an Emergency Medical Service report dated 03/17/2015 revealed Patient #8 was a 21 year old female. Patient #8 had a history of bipolor, schizophrenia, borderline personality disorder, self mutilation, suicide attempts and bowel resection. The primary diagnosis documented was abdominal pain. There was also documentation that Patient #8 was taken to the hospital because the first hospital (with a psych unit) was on diversion.
Review of the rapid triage assessment dated 03/17/2015 at 10:37 p.m., revealed the reason for Patient #8's visit was a fall this am in the shower which aggravated her hernia on the left side. There was no documentation of what the pain level was at this time. According to the suicide screen Patient #8 was not currently thinking about suicide. Patient #8 was given a priority level of semi- urgent which meant her condition required one resource for a disposition decision to be reached. The patients could safely wait for an evaluation. Routine care was required. Care could be delayed for more acute patients to receive care.
Review ofanother triage assessment by another nurse revealed Patient #8 presented to the ED on 03/17/2015 at 10:27 p.m. and was triaged at 10:37 p.m. The complaint listed on the triage assessment was fall and suicide attempt. Patient #8 was given a priority level of 2 which meant emergent. The condition required her to have expeditious treatment. The patient had the potential threat of loss of life, organ, limb or vision and should be seen as soon as possible in the ED or any other appropriate safe environment.

At 10:45 p.m. , a nurse practitioner screened Patient #8 for a fall and injury to the abdominal area.

At 11:25 p.m. (almost an hour later) Patient #8 was given the pain medication Morphine for a pain level of 10 (0 indicating no pain and 10 indicating severe pain).

At 1250 a.m. (03/18/2015) Patient #8 was asked about her pain level and said it was a little better, but still hurts. There was no documentation of what the pain level was at this time. According to documentation the Nurse Practitioner walked in the room to discuss labs and computed tomography (CT) results with the patient. Patient #8 asked "Well did I tell yall about my psychiatric history and how I'm feeling right now? ...Patient #8 stated "Well I feel like I want to hurt myself now and I didn't take my medication tonight". The nurses documented that Patient #8 placed her hands in a choking position around her neck. She took them off and starting slamming arms of a wheelchair up and down and had a look of irritability on her face and anger. Patient #8's friend stepped back due to being scared and the ER (emergency room) staff encouraged the patient to calm down and they would help her. Patient #8 stayed very agitated, now was up and walking around the room and started to walk out of the room into the nursing station area. Another ER nurse was with the patient and trying to encourage her to calm down and go back into the room ...Police was called for assistance.


At 1255 a.m. (03/18/2015) Patient #2 started walking toward the exit. A RN (Registered Nurse) was trying to calm Patient #8 down and reassuring her since the patient had not been discharged and still had IV (intravenous) in her arm. Patient #8 became more agitated and it was documented another RN was getting the police officer at this time. Patient #8 reached for the cord to the blood pressure / vital sign machine and preceded to wrap cord around her neck trying to strangle herself. At that time 2 RN's attempted to pull cord from patient's neck to protect her airway, but unable to pull cord off. The nurse practitioner was also at patient's side to assist. Police officer #4 at Patient #8's bedside and able to pull the cord off of the patient's neck. Police officer #4 placed Patient #8 into handcuffs for her safety and the ER staff's security. Patient #8 was awake, alert and oriented at that time. She was in no respiratory distress and had redness and abrasion to her neck. She was placed in a room with the door open. All cords, tables, gloves, and belongings removed from the room. Police officer #4 remained at the bedside with Patient #8.


At 1:05 a.m. (03/18/2015), there was documentation of Patient #8 being handcuffed and Police officer #4 was at the bedside. Patient #8 was on suicide precautions.

At 1:07 a.m.(03/18/2015) nursing documented a psychiatric assessment on Patient #8 and described the same events that occurred at 1255 a.m.

At 1:44 a.m., (03/18/2015) underneath the status event history section the following was documented "Transfer/MOT".

At 1:54 a.m., (03/18/2015) nursing documented Patient #8 remained handcuffed and Police officer #4 was at the bedside.

At 2:00 a..m. (03/18/2015) the nurse practioner documented Patient #8 was medically cleared for psych unit, stable and an EMTALA EMC was present. ED physician #10 signed off on the assessment.

At 3:22 a.m., (03/18/2015) Patient #8 was taken by handcuff with the police department to another hospital for an emergent psych evaluation.



Review of a statement provided by Police officer #4 revealed when the event occurred he was working a secondary employment at the hospital providing security. Police officer #4 documented due to observing the patient having the cord around her neck, pulling tight, and making the statement of wanting to kill herself, he took custody of the patient. He advised the patient that she was now being held on an emergency committal and she was not free to leave. After all the paperwork was completed and Patient #8 was medically cleared from the hospital he asked for a transport unit to take her to the psych hospital.


Review of the record revealed no physician certification, memorandum of transportation (MOT)form, copy of police warrant and no notification to the receiving hospital of the patient coming. There was also no physician's order for seclusion/restraint usage or suicide precautions.

Review of ED nursing notes from the receiving hospital revealed Patient #8 presented on 03/18/2014 at 4:18 a.m.. Patient #8 and was brought to the receiving facility (psych facility) initially by the police department on an emergency detention. The psych facility was unable to accept the patient and she was brought to the ER (emergency room) which was also a part of the receiving facility.


Review of the chart from the receiving hospital revealed documentation of Patient #8 presenting to their facility at 4:18 a.m. on 03/18/2015. There were copies of lab, other test, and the nurse practitioner screening from the transferring hospital. There was no MOT on the chart from the transferring hospital. Review of the ED notes revealed Patient #8 continued to exhibit behavior problems and was given two psychotropic medications in the ED. Patient #8 remained in the ED unit 7:35 a.m., until a bed became available in the psych unit at the facility.



During interviews on 04/01/2015 after 12:00 p.m. the following was reported:

Staff #2 and #5 confirmed the missing information in the chart.

Staff #5 confirmed the events that occurred in the ED and reported that after the incident Patient #8 was handcuffed the entire time. Staff #5 reported the police officer said he had an emergency warrant and called for a patrol car to take Patient #8 to the psych hospital. If the police officer was not involved they would have put the patient on 1:1 supervision, took care of her immediate needs, physician consulted with psych hospital, and transferred with a MOT. Staff #5 reported the receiving facility called them the next day (03/19/2015) and said they were reporting them for a possible EMTALA violation. Staff #5 reported they performed an investigation, but nothing was done. The reason given by Staff #5 for not notifying the receiving hospital was that Patient #8 was discharged to the police officer. They did not know where he was taking her and considered it a transport instead of a transfer.

ED Physician #10 reported he agreed with the nurse practitioner's medical screening. ED Physician #10 reported he told the officer he needed to call the psych hospital to let them know Patient #8 was coming there. He was told by Police officer #4 he did not need to call the hospital and he complied. ED Physician #10 reported normally he called the hospital of patients being transferred.


During interviews on 04/02/2015 after 9:00 a.m. the following was reported:

Receiving hospital staff #11 reported Patient #8 was sent to their hospital and they had not received a call from the transferring hospital about the transfer nor a MOT. Staff #11 reported their ED was on diversion at the time and she was not sure of the reason why.

Police officer #4 confirmed Patient #8's behavior and what was described in his statement. Police officer #4 reported when he heard Patient #8 say she was going to kill herself, he took custody of her and handcuffed her to the bed. After Patient #8 was medically cleared he called for a patrol car to take her to the psych unit. Patient #8 was taken to the psych unit and the receiving hospital let her walk back out the door. Police officer #4 reported Patient #8 walked back out of the hospital and told the officer they would not keep her. The police lieutenant had to call someone in hospital's administration over the problem and they were instructed to take Patient #8 over to the main hospital ED. Police officer #4 reported custody was taken again over Patient #8 and she was taken to the main hospital ED. Police officer #4 reported they were having trouble with the receiving hospital going on diversion so they do not have to accept patients. The hospital can deny the police if they call first, but they can not if they just show up with a patient.



Review of Memorandum of Transfer forms revealed the following missing items:

Patient #26 (12/05/2014), initial contact with receiving hospital, accepting physician secured by transferring physician, accepting hospital information, type of vehicle and company used, personnel-equipment used, type of vehicle, diagnosis, and signature of patient or authorized person.


Patient #31 (01/05/2015), Patient #12 (01/21/2015), Patient #27 (02/02/2015), Patient #30 (02/12/2015)other risk and benefits section underneath physician certification was left blank.

Patient #29 (01/13/2015) and Patient #28 (01/23/2015), were transferred from another facility and the facility failed to complete the portion designated for the receiving hospital.




Review of facility policies revealed the following:

*Title: "Suicide Risk Assessment of Patients" dated 01/13/2013

"All patients presenting to the emergency department with suicide thoughts, attempts or gestures will be medically screened, treated, assessed for suicide risk and referred, transferred or admitted in patient for their other other emergency medical conditions. If no other emergency medical conditions exist, those patients will be properly referred or transferred to the appropriate psychiatric facility for follow-up care."


*Title : Transfer/Transport Of Patients To Or From Another Facility/Campus" dated 12/2013

"DEFINITIONS:

1. Transfer -Movement of a patient from an originating area of care to a receiving area of care with the intent of that patient remaining in the receiving area indefinitely.

POLICY:

3. The movement of a stable patient from one hospital to another hospital for the purpose of outpatient testing, not provided at the first hospital, is not considered to be a transfer, rather it is considered a transport. However, appropriate transfer documentation, certification, and acceptance by the receiving hospital must still be effectuated. The intent is that the patient should return to the original hospital after testing. Memorandum of Transfer form (MOT) is not required in this situation. This applies only when a patient remains stable during transfer to and from hospitals and during testing.

PROCEDURE:
1. GENERAL INFORMATION:

D. Federal and State transfer laws, rules and regulations have defined specific requirements and obligations to facility hospital to hospital patient transfers. These include:

II. Patients with emergency medical conditions may be transferred for medical necessity. The transferring LIP(Licensed Independent Practitioner) must sign a certification stating that the benefits outweigh the risks of the transfer.
III. The transferring hospital must make contact with the Administrative Representative (ex. Charge nurse/unit director/shift coordinator/access nurse) of the receiving hospital assuring its capacity and capability to treat the transferred patient.

2. TRANSFER TO ANOTHER ACUTE CARE FACILITY
D. Memorandum of Transfer (MOT):
I. The hospital should provide a Memorandum of Transfer to be completed for every patient who is transferred.
II. The Memorandum of Transfer must be signed by the hospital administrative representative(ex. Charge nurse/unit director/shift coordinator/administrative supervisor) and assure completeness of form.
III. Send original Memorandum of Transfer to accepting location."