HospitalInspections.org

Based on review of facility documents, medical records (MR), and staff interview (EMP) it was determined the facility failed to ensure a safe and appropriate transfer of a psychiatric patient for one of 10 medical records reviewed (MR1).

Review on August 25, 2022, of the facility policy, "EMTALA (Emergency Medical Treatment And Active Labor Act) - Administrative," last reviewed April 2022 revealed "... I. Policy: ... 2. Medical Stabilization A. The Hospital must provide necessary stabilizing treatment within its capability or an appropriate transfer to any person who is determined to have an emergency medical condition. Such stabilizing treatment must be provided in a non-discriminatory manner (i.e. a different level of care must not exist based upon age, sex, race, ethnic origin, religion, sexual preference, medical condition, insurance, or ability to pay.). ... 5. Transfer of Patients to Another LVHN Facility / Site or to a Non-LVHN Facility A. Inpatients, ED or Express Care patients may be transferred to another facility for various reasons: 1) Request by patient, or their authorized representative, for any reasons which may or may not be medical. 2) The benefit of more appropriate facilities and/or services. ... II. Definitions: ... Appropriate Transfer: Those that meet the following criteria: 1. The transferring hospital must provide the medical treatment within its capacity which Minimizes the risks to the individual's health and, for a woman in active labor, to the fetus. 2. The receiving facility must have available space and qualified personnel for the treatment of the individual, and must have agreed to accept the transfer. 3. The transferring hospital must send or make available copies of all appropriate medical records and radiology films (such as CAT Scan, MRI, Chest X-ray, etc.) available at the time of transfer to the receiving facility. 4. The transfer must be made by qualified personnel and with appropriate transportation equipment including any necessary life support. ... Emergency Medical Condition (EMC): 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in a. placing the health of the person (or, with respect to a pregnant patient, the health of the patient or the fetus) in serious jeopardy; b. serious impairment to bodily function; or c. serious dysfunction of any bodily organ or part; or ... EMTALA: Refers to sections 1866 and 1867 of the Social Security Act, 42 U.S.C. Section 1395dd, which obligate hospitals to provide medical screening and treatment or appropriate transfer of individuals with emergency medical conditions or women in labor. ... Medical Screening Exam (MSE): A medical screening examination is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists or an individual is in labor. Such screening must be done within the facility's capability and available personnel, including on-call providers and be applied in a non-discriminatory manner (i.e., a different level of care must not exist based upon age, sex, race, ethnic origin, religion, sexual preference, medical condition, insurance, or ability to pay). Screening is to be conducted to the extent necessary, by providers and/or other qualified medical personnel, to determine whether an emergency medical condition exists. With respect to a person with psychiatric symptoms, an MSE consists of both a medical and psychiatric screening. The MSE is an ongoing process and the medical records must reflect continued monitoring based on the person's needs and must continue until the individual is either stabilized or appropriately transferred. ... Stable Patient: A patient whose medical condition should not, within reasonable medical probability, deteriorate during transfer. ... B. Emergency Department Patient Transfers to another Hospital Emergency Department Provider will: 1) Notify patient or authorized representative of reason for transfer, explain risks and benefits of transfer, and document same in the patient's medical record. ... 7) Order appropriate mode of transportation, equipment and level of transport service personnel. Emergency Department Clinical Staff / Case Manager will: 1) Confirm bed availability and notify receiving institution of transfer. 2) Arrange transportation, equipment and personnel as necessary through the CAT Department. ..."

Review on August 25, 2022, of the facility policy, "302 Involuntary Commitment - Administrative," last reviewed January 2022 revealed "... II. Definitions: ... 302 Commitment - An emergency detention, specifically for the purpose of evaluating a client for dangerousness to self or others for mental illness. Medically cleared - The ability to treat the patient medically on an outpatient basis. PES: Psychiatric Evaluation Services- Mental Health professionals who assess/evaluate behavioral health patients for level of care determination, risk assessment, and manage commitment and referral processes as appropriate. PES may be referred to as Case managers, Crisis intervention workers, Crisis assessment counselors. III Procedure: ... 3. The Emergency Department provider or, when possible, a psychiatrist will evaluate the patient to determine if he/she is severely mentally disabled and in need of immediate inpatient treatment. Note: a patient must be evaluated within two hours of completion and delegation of the petition, (or arrival to the Emergency Department if petition is completed prior to arrival). This is subject to local county rules and procedures. ... 5. If, after evaluation, the patient is considered "not severely mentally disabled", [sic] arrangements must be made for the patient's immediate release and return to their location prior to the involuntary examination. ... 8. Should the patient's medical condition warrant inpatient care, the original completed 302 Commitment Application is to be scanned into the EHR and a copy of the original completed 302 Commitment Application with the patient's medical record is sent to the admitting facility. ..."

Review on August 25, 2022, of MR1 revealed MR1 arrived at the facility Emergency Department (ED) on August 18, 2022, at approximately 1730 via police for a 302 Involuntary Commitment Petition. The 302 Involuntary Commitment Petition contained documentation the police officer wrote MR1 was a clear and present danger to herself. There was police documentation MR1 was found at a bus station and was not making sense. There was documentation the police contacted MR1's brother and Orange County, NY Act Team and both advised the police officer MR1 had a mental health condition and was non-compliant with medication. There was documentation MR1 had a history of taking buses and getting stranded when medication noncompliant. There was police documentation the officer did not feel MR1 was able to care for herself.

Continued review of MR1's 302 dated August 18, 2022, revealed physician documentation which stated MR1 was a 61-year-old with a history of bipolar disorder and medication noncompliance. There was physician documentation MR1 was delusional and making poor decisions. The physician documented treatment needed: inpatient psychiatric treatment, 945 to be completed by ACT in NY (per court order). The physician documented on the 302 form: The patient was not in need of emergency involuntary treatment. H/she shall be returned to a place which h/she shall reasonably designate.

Continued review of MR1 revealed physician documentation in the ED provider note dated August 18, 2022. There was physician documentation MR1's 302 was denied as per ACT team in NY and patient would be transported home for completion of 945 in NY at 2100 on August 18, 2022. There was additional physician documentation on August 18, 2022, at 2316 the patient had a ride to New York where she will be hospitalized.

Interview on August 25, 2022, with EMP3, at approximately 1000, confirmed MR1 contained documentation MR1 was brought to the facility ED on August 18, 2022, via police escort for petition of a 302 Involuntary Commitment. EMP3 confirmed MR1 contained physician documentation MR1 needed psychiatric inpatient treatment and a 945 was to be completed in New York. EMP3 was unable to explain what a 945 was. EMP3 confirmed there was physician documentation MR1's 302 was denied per the New York Act team and the patient had a ride to New York where she would be hospitalized.

Continued review of MR1 revealed a case management note dated August 18, 2022, with the following documentation: MR1's brother reported the patient had a history of eloping but never so far. MR1's brother was unable to pick MR1 up at facility due to the hour but contacted and confirmed transportation from the facility ED to a New York hospital ED where the ACT team had begun the 945 process equivalent to PA 302 involuntary commitment. There was documentation the ACT team reported the patient was court ordered to be medication compliant or would be sent as an inpatient to the hospital. There was case management documentation the New York hospital was awaiting her arrival to resume inpatient mental health treatment.

Interview on August 25, 2022, with EMP3, EMP4, EMP5, and EMP9, confirmed no Lehigh Valley Hospital - Pocono staff spoke to the receiving New York hospital regarding MR1 on August 18 and 19, 2022.

Continued review of MR1 revealed an Orange County New York Court Order of Assisted Outpatient Treatment for MR1. The order was dated and signed June 9, 2022, and stated MR1 met criteria for Assisted Outpatient Treatment as set forth in New York Mental Hygiene Law 9.6(c). There was documentation in the Order MR1 was to accept Assisted Outpatient Treatment for a period of one year which included MR1 was to receive all outpatient psychiatric services, prescribed medications, medication monitoring, individual and group therapy through the Orange County ACT Team. There was documentation should MR1 refuse outpatient treatment there was court ordered permission the patient would be taken into custody and transported to a hospital for evaluation and treatment if necessary.

Interview on August 25, 2022, with EMP4 at approximately 1500, revealed this court order from the state of New York was not received by the hospital until the day after MR1's discharge from Lehigh Valley Hospital - Pocono. EMP4 confirmed they did not have the court order in hand while MR1 was a patient at the facility. EMP4 revealed they were informed of such a court order by the New York Act Team via telephone on the evening of August 18, 2022.

Continued review of MR1's case management note dated August 18, 2022, revealed documentation MR1's brother set up transportation for MR1 to the New York Hospital ED and the driver was to make no stops and go directly to the hospital. MR1's brother would call the facility once she arrived. There was case management documentation the physician ordered Ativan for patient before leaving the facility for her ride to New York.

Interview on August 25, 2022, with EMP3, at approximately 1030 confirmed MR1 contained case management documentation MR1's brother arranged transportation for MR1 to be transported to a New York hospital for inpatient psychiatric treatment. EMP3 confirmed MR1 also contained case management documentation the driver was to make no stops and go directly to the hospital and a physician order for Ativan was obtained for MR1's ride to New York.

There was nursing documentation MR1 was administered Ativan 1 milligram (mg) by mouth at 0014 on August 19, 2022. There was documentation MR1 was discharged via wheelchair and transported to New York on August 19, 2022, at 0052.

Interview on August 25, 2022, with EMP3, at approximately 1045 confirmed MR1 was administered Ativan 1 mg by mouth at 0014 on August 19, 2022 and MR1 was discharged via wheelchair and transported to New York on August 19, 2022, at 0052.

Review on August 26, 2022, of the New York receiving hospital medical record for MR1 revealed the receiving hospital received a call on August 19, 2022, from the New York Act team MR1 was being transported to their facility after being found at a bus station and would need a psychiatric evaluation. There was documentation MR1 arrived at the receiving hospital on August 19, 2022, at approximately 0222 via taxicab from Lehigh Valley Hospital - Pocono after being medicated with Ativan. There was documentation no report was received. There was documentation the patient appeared extremely psychotic upon arrival to receiving hospital ED and MR1 required assistance out of the taxicab. There was documentation the taxicab driver handed MR1's involuntary commitment papers to the receiving hospital staff and stated the patient was medicated prior to leaving Lehigh Valley Hospital - Pocono. There was nursing documentation the NY ACT team told nursing staff MR1 had insurance issues at Lehigh Valley Hospital - Pocono, so her brother asked her to be sent to the New York hospital in a cab.

Continued review of the receiving facility's medical record revealed physician documentation dated August 19, 2022, which stated MR1 was evaluated and found to be disorganized, bizarre, illogical, nonsensical, delusional, paranoid, and in need of psychiatric admission for stabilization. There was physician documentation MR1 was a danger to herself and needed psychiatric admission for stabilization. There was documentation MR1 was admitted to the facility Behavioral Health Unit on August 19, 2022.

Interview on August 26, 2022, with EMP6, at approximately 1230 confirmed MR1 contained documentation MR1 was brought to the receiving hospital via taxicab on August 19, 2022. EMP6 confirmed MR1 contained documentation did not receive report from Lehigh Valley Hospital - Pocono and MR1 was psychotic and needed assistance out of the vehicle upon arrival. EMP6 confirmed MR1 was determined by a physician to be a danger to herself and needed inpatient psychiatric treatment and was admitted to the receiving facility's Behavioral Health Unit.