HospitalInspections.org

Based on interview and record review the facility failed to obtain signed physician certifications deeming the risk and benefits of transfers on patients with emergency medical conditions. This was found for 6 of 6 months (January 2016 through June 2016).


This deficient practice had the likelihood to affect all patients.



Findings include:

Review of the facility's "MEMORANDUM OF TRANSFER LOG" (MOT) for the timeframe of January - June 2016 revealed the following:


January 2016

Review of 26 of 28 MOT's were found to not have a physician's signature attesting to the transfer.

February 2016

Review of 34 of 35 MOT's were found to not have a physician's signature attesting to the transfer.

March 2016

Review of 33 of 38 MOT's were found not have a physician's signature attesting to the transfer.

April 2016

Review of 18 of 22 MOT's were found to not have a physician's signature attesting to the transfer.

All but 2 records reflected an order had been received by a Registered Nurse and were never signed by the physician.

Two records were not signed, timed, or dated by either a Registered Nurse or the physician.

During an interview on 6/28/2016 after 5:00 p.m., Staff #4 and Staff #5 confirmed the MOT's were not signed by the physician.




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May 2016
Review of 18 of 23 MOT's revealed nursing staff documented taking a verbal order for the transfers and signed the forms for the physicians. There was no countersignature by the physician certifying the forms. One MOT was dated 06/23/2016 and the physician signature line was blank as of 06/28/2016 (5 days later).

June 2016

Review of 18 of 23 MOT's revealed nursing staff documented taking a verbal order for the transfers and signed the forms for the physicians. There was no countersignature by the physician certifying the forms. One MOT dated 05/20/2016 and another dated 05/23/2016 revealed the physician signature line was blank as of 06/28/2016 (over a month later).



SUBJECT: MEDICAL SCREENING, CONSULTATIONS, TREATMENT, AND TRANSFER POLICY (" EMTALA "Policy)"
II. TRANSFERS TO THE HOSPITAL.
"D. Transfer.
1. The Hospital may not transfer a patient with an emergency medical condition that has not been stabilized unless:
b. A licensed physician has signed a certification, including a summary of the risks and benefits, that based on the information available at the time of transfer, the medical benefits reasonable expected from the provision of appropriate medical treatment at another hospital out weigh the increased risk to the patient, and, in the case of labor, to the unborn child effecting the transfer; or
c. If a licensed physician is not physically present in the Emergency Department at the time that a patient is transferred, a qualified medical person has signed the above described certification, after a physician, in consultation with the person, agrees with the determination regarding the risks and benefits and subsequently countersigns the certificate."

Based on interview and record review the facility failed to accept the transfer of a patient requiring a higher level of care and specialized facilities. They refused to accept a patient based on residence and the inability for the local court system to be reimbursed. This deficient practice was found in 1 of 1 patients (Patient #1).

This deficient practice had the likelihood to cause harm in all patients presenting to the emergency room.

Findings include:



Review of the ED (emergency department) notes revealed Patient #1 was a 52 year old female who presented to Hospital A on 06/19/2016 at 11:01 a.m.
According to the ED nurse's notes timed 11:08 a.m., Patient #1 presented to the ED via EMS (Emergency medical services) with complaints of a suicide attempt. Patient #1 had lacerations to the left wrist and per EMS was cut with a knife. There was documentation that Patient #1 had an altercation with her spouse this am and no psychiatric medications had been taken for two months.
Review of a psych screen dated 06/19/2016 revealed Patient #1 needed in-patient treatment.
Review of a "Physician's Certification of Medical Examination for Mental Illness" dated 06/19/2016 revealed the following:
"Pt with self-inflicted laceration to left wrist an attempt to end her life"
"9. (NOTE: COMPLETE THIS STATEMENT ONLY IF THIS CERTIFICATE IS TO BE OFFERED IN SUPPORT OF COURT-ORDERS MENTAL HEALTH SERVICES FOR THE PATIENT UNDER A VOLUNTARY COMMITMENT WHO REFUSES TO CONSENT TO NECESSARY AND APPROPRIATE TREATMENT.)
The Patient is receiving voluntary inpatient services and has refused necessary and appropriate treatment, and in my opinion:
A. there is no reasonable alternative to the treatment recommended by the physician; and
B. the patient will not benefit from-continued inpatient care without the recommended treatment.
____(CHECKED)_______YES ________________NO "
Review of a "Hospital Transfer Record" from Hospital A dated 06/19/2016 revealed a request for transfer was made to Hospital B at 4:26 p.m.
According to the documentation Staff #7 from Hospital B was called to see if "they would consider taking either of the two 'voluntary' patients we have in the ED. She advised they have to be involuntary ..."
At 5:27 p.m.,Info faxed to Staff #7.
At 7:41 p.m., Staff#7 replied "Must deny. No bed avail. Court day tomorrow, may have bed then."

Review of a "Hospital Transfer Record" from Hospital A dated 06/20/2016 revealed the following on Patient #1:
At 8:00 a.m. ,"Still has the paperwork. Will have physician look at paperwork after court. They should have some discharges."
At 12:45 p.m., "Still waiting for physician to review the paperwork."
At 4:25 p.m., " Staff #7 has to check with administration because this patient is a resident of Sabine County.'

During an interview on 06/28/2016 after 2:00 p.m., Staff #6 (Hospital B) went over staffing numbers for 06/19/2016 on the adult behavioral unit. Staff #6 confirmed they had enough staff numbers for a patient census of 15. Staff #6 reported they had a total of 19 beds on the adult unit and a census of 15. According to the staffing matrix they had enough staff for one extra patient on the unit. Staff #6 reported the staff usually call her and she would move patients and staff around to accomodate the increase in patients, but this was not done by her on 06/19/2016. Staff #6 did not move patients around because staff informed her they could not take anymore patients. Staff #6 also confirmed they were not keeping an accurate transfer log. They found out from this incident that staff were only logging the names of patients that were being accepted to the units.

During an interview on 06/28/2016 after 3:30 p.m., Staff #7 (Hospital B) confirmed she talked to staff at Hospital A on 06/19/2016 and 06/20/2016 about Patient #1. Staff #7 confirmed her hand writing on the paperwork that was faxed over to them from Hospital A. Staff #7 confirmed she had written the following statement in red on the paperwork "Sabine Co./ Cannot accept this one.(Hospital A) informed." Staff #7 denied making any reference to their hospital not getting paid for the Patient #1, but confirmed talking to a male staff member from Hospital A. Staff #7 reported Patient #1 was denied because of the hospital not having enough beds. Staff #7 confirmed she had not added Patient #1's name on their transfer log. The reason given was that they only documented the names of patients they accepted on the log.
During an interview on 06/29/2016 after 9:30 a.m., Staff #15 (male from Hospital A) confirmed he was the staff member that talked to Staff #7 on 06/20/2016. Staff #15 reported he was just filling in for one of his staff members that had stepped away from the phones. Staff #15 reported Staff #7 called and accepted two other psych patients (Patient #'s 14 and 30) and reported they were not able to take Patient #1 because she was from Sabine county and that was out of their catchment area. Staff #15 confirmed they recorded their calls and had the conversation on tape.

Review of the tape with Staff #15 on 06/29/2016 after 10:30 a.m. revealed the following:
Staff #7 identified herself and where she was calling from. Staff #7 informed Staff #15 that they would not be able to accept Patient #1 because she was from Sabine county. It was out of their catchment area and the courts would not pay the court cost for her. Staff #7 reported they had gotten chewed out earlier in the day for that by the judge. Staff #7 also reported they were going to accept Patient #14 and 30. They were going to be moving beds around to accept Patient #14. They also had another in-patient from Hospital A they were going to accept.

Review of a "Hospital Transfer Record" from Hospital A dated 06/20/2016 revealed the following:
Patient #14 was a 44 year old female who was delusional, paranoid, suicidal, and homicidal and had drug induced psychoses.
At 8:00 a.m., Staff #7 "has the paperwork, Today is court day and she will have discharges. She will have the physician look at the paperwork and call back after court."
At 4:20 p.m., Staff #7, "Pt needs CK"(creatinine kinase).
At 6:04 p.m., Dr #18 accepts at 6:04 p.m. Admin approval given by Staff #7.

Review of a "Memorandum of Transfer" from Hospital A revealed Patient #30 was a 22 year old male with a diagnosis of suicide overdose. Initial contact was made with Hospital B on 06/20/2016 at 9:23 a.m. At 4:25 p.m. the accepting Hospital B was secured and Staff #7 was the name of the accepting hospital administration person.

Review of a facility policy revised 06/2016 revealed the following:
SUBJECT: MEDICAL SCREENING, CONSULTATIONS, TREATMENT, AND TRANSFER POLICY ( " EMTALA " Policy) "
II.TRANSFERS TO THE HOSPITAL.
A. Acceptance or Refusal of Transfer Request
1.The hospital shall not refuse to accept an appropriate transfer of an individual with an emergency medical condition if the individual requires a specialized service (e.g. neonatal intensive care unit) available at the Hospital, if the Hospital has the capacity and capabilities necessary to treat the individual, and the transferring facility does not have the specialized services needed.