HospitalInspections.org

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

Failing to ensure for the appropriate transfer of psychiatric patients (evaluated to be a danger to self and/or others and placed on a Physician's Emergency Certificate) who were in need of acute inpatient psychiatric services of which the sending hospital was unable to provide at the time of transfer. This was evidenced by the hospital's failure to ensure 18 (#1, #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20) of 20 (#1- #20) psychiatric patients were transferred from the sending hospital to the receiving hospital by individuals who were appropriately trained and/or qualified to provide for the safe and effective transport of a patient in need of acute inpatient psychiatric services. The hospital allowed Company A to transport these patients using a single driver who had no training in medical and/or psychiatric emergencies and no training in the use of psychiatric de-escalation techniques. (see findings tag A- 2409).

Based on record review and interview, the hospital failed to ensure for the appropriate transfer of psychiatric patients (evaluated to be a danger to self and/or others and placed on a Physician's Emergency Certificate) who were in need of acute inpatient psychiatric services of which the sending hospital was unable to provide at the time of transfer. This was evidenced by the hospital's failure to ensure 18 (#1, #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20) of 20 (#1- #20) psychiatric patients were transferred from the sending hospital to the receiving hospital by individuals who were appropriately trained and/or qualified to provide for the safe and effective transport of a patient in need of acute inpatient psychiatric services. The hospital allowed Company A to transport these patients using a single driver who had no training in medical and/or psychiatric emergencies and no training in the use of psychiatric de-escalation techniques.

Findings:

Review of the hospital's policy titled Patient Transfer, revealed in part:
5. The patient's transfer will be by ambulance, air ambulance, or other transportation as deemed appropriate by the transferring physician. The attending physician has the responsibility to ensure that the transfer is effectuated through personnel with appropriate education, training and skill level, and appropriate equipment to maintain the designated level of care.

Review of the contract between the hospital and Company A revealed in part:
1. Company A would provide secure one-way transportation for PEC patients of Hospital to any psychiatric and/or chemical dependent treatment facility within the state of Louisiana.
5. Violent patients have to be mildly sedated at time of pick up.
7. In the event of an emergency during transport, such as illness, Company A will notify the treating physician and hospital. Company A's staff will not and shall not be held responsible to administer first aid.
8. Company A is not responsible for the medical care of the patients of Hospital nor will Company A seek services other than for emergency care as warranted during transport.

Patient #1
Review of the medical record for Patient #1 revealed he presented to the ED 7/02/16 with violent behavior and homicidal ideation. The patient was placed on a PEC (Physician Emergency Certificate). He was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 25-30 minutes.

Patient #2
Review of the medical record for Patient #2 revealed he had arrived to the Hospital's Emergency Department on 7/28/16 at 10:29 a.m. by police escort with the complaint of Emotional Disturbance. Further review revealed he was transferred to a local psychiatric hospital on 7/28/16 at 10:50 p.m. Patient #2's transportation mode was Company A. The travel time to the receiving facility was approximately 15 minutes.

Review of the PEC for Patient #2 dated 7/28/16 at 1:37 p.m. revealed the following:
History of Present Illness: 26 year old AAM (African American male) presents in a psychotic/manic/ intoxicated state, BIB (brought in by) police in handcuffs, dressed in rainbow colored clothing, dancing and not able to communicate verbally in a meaningful manner.
Mental condition: Psychotic/hostile/violent
Patient is currently: Violent
It is in my opinion that the above person named is in need of immediate psychiatric treatment in a treatment facility because he/she is seriously mentally ill or suffering from substance abuse so that he/she is dangerous to self, unwilling, dangerous to others, gravely disabled, unable to seek voluntary admission.

Patient #4
Review of the medical record for Patient #4 revealed he presented to the ED 6/28/16 with agitation and auditory hallucinations. The patient was placed on a PEC. He was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 1 hour and 10 minutes.

Patient #5
Review of the medical record for Patient #5 revealed he presented to the ED 6/24/16 with violent behavior, history of conduct disorder and explosive disorder. The patient was placed on a PEC. He was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 3 hours and 45 minutes.

Patient #6
Review of the medical record for Patient #6 revealed she presented to the ED 7/01/16 on an OPC for bizarre and delusional behavior. The patient was placed on a PEC. She was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 25-30 minutes.

Patient #7
Review of the medical record for Patient #7 revealed he presented to the ED 7/04/16 with violent behavior. The patient was placed on a PEC. He was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 1 hour and 30 minutes.

Patient #8
Review of the medical record for Patient #8 revealed the 13 year old male presented to the ED 7/5/16 with violent behavior and homicidal ideation. The patient was placed on a PEC. He was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 3 hours and 45 minutes.

Patient #9
Review of the medical record for Patient #9 revealed he presented to the ED 7/5/16 with violent behavior and suicidal. The patient was placed on a PEC. He was transferred to a local facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 15-20 minutes.

Patient #10
Review of the medical record for Patient #10 revealed he presented to the ED 7/8/16 with agitation and violent behavior. The patient was placed on a PEC. He was transferred to a local facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 15-20 minutes.

Patient #11
Review of the medical record for Patient #11 revealed she presented to the ED 7/15/16 with bizarre/paranoid behavior and auditory hallucinations. The patient was placed on a PEC. She was transferred to a local facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 15-20 minutes.

Patient #12
Review of the medical record for Patient #12 revealed he presented to the ED 7/18/16 on an OPC with aggressive behavior. The patient was placed on a PEC. He was transferred to a facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 20-25 minutes.

Patient #14
Review of the medical record for Patient #14 revealed she presented to the ED 7/11/16 with combative behavior and a history of dementia. The patient was placed on a PEC. She was transferred to a facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 20-30 minutes.

Patient #15
Review of the medical record for Patient #15 revealed she presented to the ED 7/11/16 with violent behavior. The patient was placed on a PEC. She was transferred to a facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 15-20 minutes.

Patient #16
Review of the medical record for Patient #16 revealed she presented to the ED 7/11/16 with manic behavior. The patient was placed on a PEC. She was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 15-20 minutes.

Patient #17
Review of the medical record for Patient #17 revealed he presented to the ED 7/1/16 with violent and combative behavior, history of schizophrenia. The patient was placed on a PEC. He was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 10-15 minutes.

Patient #18
Review of the medical record for Patient #18 revealed she presented to the ED 7/15/16 with complaints of assault (on herself), Alcohol abuse, and suicidal ideations. The patient was placed on a PEC. She was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 15-20 minutes.

Patient #19
Review of the medical record for Patient #19 revealed he presented to the ED 7/16/16 with aggressive behavior, homicidal ideations, and history of Schizophrenia. The patient was placed on a PEC. He was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 15-20 minutes.

Patient #20
Review of the medical record for Patient #20 revealed he presented to the ED 7/27/16 on an OPC, for violent behavior. The patient was placed on a PEC. He was transferred to another facility for inpatient treatment, via Company A. The travel time to the receiving facility was approximately 15-20 minutes.

In an interview on 8/5/16 at 1:30 p.m. with S3RN, she said when a psychiatric patient needed to be transferred the nurse would select the method of transfer which was usually Company A. S3RN said the physician did not select a mode of transfer. S3RN said the physician would sign the Certificate of Transfer which listed the mode of transportation. S3RN also said if Company A transferred a patient it was just a driver and the patient in the vehicle. S3RN said the car for Company A was like a cop car and had a cage between the front and back seats. S3RN said if the patient began acting out, the driver would pull on the side of the road and call EMS or go to the nearest ED. S3RN said there was no staff during transport to attend to the patient.

In an interview on 8/5/16 at 4:50 p.m. with S7MgrCompany A, she said she was the Operations Manager for Company A. S7MgrCompany A said the drivers of the transport vehicles drove alone and their job was simply to transport patients. S7MgrCompany A said the drivers were not medical and did not have any training in patient care or how to handle psychiatric patients. S7MgrCompany A said the driver was only required to keep a visible eye on the patients. She said if the patients ran the driver did not chase them. S7MgrCompany A said if the patient began acting violently or hurting themselves during transport, the drivers would call the facility to come out and get the patient. S7MgrCompany A said if they were not near a hospital they would call the State Police to come get the patient. She said the driver could try to talk to the patients and calm them down but would never open the door to the back of the vehicle. S7MgrCompany A also verified the receiving hospital could sometimes be hours away from the sending hospital.

In an interview on 8/8/16 at 9:00 a.m. with S5MD, he said he was the medical director for the behavioral health service line at the hospital. S5MD said psychiatric patients transferred were transported by a local ambulance company or Company A. S5MD said when patients were transported by Company A he was not sure of how many staff members were in the van with the patient or if the transporters could restrain patients. S5MD said he had not seen the contract between the hospital and Company A. S5MD said in the unit at the hospital the patients were directly observed at all times by staff. S5MD said that there was an abundance of caution because they were in an acute psychiatric facility for their safety. S5MD said the psychiatric patients were unpredictable and someone that had a PEC had a wide range of behaviors. S5MD said he agreed certain patients may not be safe during transport with a single driver without training.

In an interview on 8/8/16 at 9:41 a.m. with S1Director, she said she was the Executive Director of Mental and Behavioral Health services at the hospital. S1Director said she did not know how many people were in the vehicle during transport by Company A or if they were trained. S1Director said she had never seen the contract. S1Director said the transferring facility was responsible for providing safety during transport. S1Director said it was the physician's decision as to the type of transport.

In an interview 8/8/16 at 10:20 a.m. with S8Driver, he verified he was employed by Company A and said that he normally worked alone when he transported. S8Driver indicated that if he had a problem with a patient such as a medical one, or the patient was becoming violent or self-harming, he would drive to the nearest ED. S8Driver reported that he was not allowed to open the patient's car door. S8Driver reported that he has had to stop in the past at the nearest ED he could find because a patient was trying to harm themselves in the back seat. S8Driver said that he had patients that would bang their heads on the windows or screen and he had to divert to the closest hospital. S8Driver further indicated that even if he was in a remote area he still had to continue driving to the nearest hospital or pull over and call the state police. S8Driver also verified that the drivers had no specialized psychiatric training and were not required to have CPR. S8Driver said they strictly drove the transport vehicle.

In an interview on 8/8/16 on 10:32 a.m. with S4MD, he said he was an Emergency Medicine physician. S4MD said when the psychiatric patients were ready for transport, the nurse would bring the transfer paperwork to the physician in the fast track area of the ER. S4MD said he is not sure why they bring the paperwork to them instead of the physician in the psychiatric unit. S4MD also said typically when the nurse sent the Certificate of Transfer for them to sign the mode of transport was Company A. S4MD said he was not sure how many people were in the Company A vehicles with the patients. He said he thought there were two or three staff in the vehicle. S4MD said he had not seen the contract and he was not aware if they had any type of training. S4MD agreed there was not continuity in care during the transport and maybe it was not safe. He said when he signed the Certificate of Transfer it was just for medical clearance. S4MD said someone in the psychiatric department determines the mode of transport but he is not sure who it is.

In an interview 8/8/16 at 10:45 p.m. with S9RN, she said she was the ED Educator. S9RN reported that when someone was transferred from the facility (ED/EMBH) there was not an actual order written to transfer the patient or for the mode of transportation. S9RN indicated the nurses arranged transportation depending on the medical or physical needs of the patients.

In an interview on 8/8/16 at 12:51 p.m. with S5MD, he said the COPE (Crisis Oriented Psychiatric Evaluation) team would set up the transfer method. S5MD said the COPE team was made of up counselors such as social workers. S5MD said the behavioral health portion of the ED did not have a requirement that the physician order the mode of transfer.

In an interview on 8/8/16 at 1:50 p.m. with S6MD, he said he was the medical director of the ED. S6MD said the EMBH gets the ED physician's to sign a Certificate of Transfer when a psychiatric patient is going to be transferred. S6MD said by signing the Certificate of Transfer the MDs are agreeing with moving the patient to a higher level of care. S6MD says he and his physicians were agreeing with the information on the Certificate of Transfer when they signed it including agreeing the mode of transfer that was selected by someone in the EMBH. S6MD said he was not sure how many people were in the transportation vehicle for Company A or what type of training they had. S6MD said the organization (hospital) had selected this service so he assumed the staff was trained. S6MD said if he didn't know what services Company A provided and indicated that none of his physicians in the ED did either.