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Based observation, interview, record review, and policy and document review, it was determined the Governing Body failed to ensure that hospital staff followed policies and procedures for assuring patient safety during transfers to other facilities (refer to A093), and failed to monitor and analyze problems with all patient transfers from the hospital (refer to A309). The cumulative effect of these deficient practices has resulted in the hospital's inability to ensure quality patient care in a safe setting.

Based on staff interview, medical record review, and hospital policy review, it was determined the hospital failed to ensure safe patient transfers for 8 out of 32 (25%) patients in the sample (Patients 7, 12, 14, 15, 18, 20, 24, 26).

Findings include:

A. Surveyor requested policies and procedures related to management of transfers for patients that are medically unstable or have emergency medical conditions. The facility provided the following:

Hospital policy titled "Management of Medical Emergency/Deterioration of Patient Condition" stated, " ...Individuals who present to SUN Behavioral for assessment for admission ...will obtain an initial infection screen prior to assessment and medical screen with 15 minutes of arrival. An RN is available around the clock to assist with this assessment in the Intake Department. A physician is on call to provide instructions, orders, and MD-MD communication related to patient transfer in or out of the hospital ..."

Hospital policy titled "Suicide Prevention Program/Assessment & Re-Assessment for Suicidal/Self Harm Ideation" stated, " ...Upon assessment in the Intake Department the patient will be assessed using the Columbia-Suicide Severity Rating Scale (CSSR-S). The assessment will include ...History of self harm thoughts and behaviors ...recent ideation, suicide attempts, risk factors ...including dates and the precipitating events leading to the attempts ..."

Hospital policy titled "Emergency Medical Treatment and Active Labor Act" stated, " ...In the event a patient ...is screened, evaluated, and determined to be medically unstable by the registered nurse on duty and requiring a level of care not provided by this facility, the following procedures will be initiated ...The attending physician and/or the on-call physician will be notified ...The physician and/or the registered nurse will notify the physician at the receiving facility of the impending transfer ...The registered nurse, upon physician's order, will contact the receiving facilities Emergency Room Supervisor to initiate arrangements necessary to assure that appropriate clinical data is exchanged between the two facilities ...Patient is transported with documentation of...condition upon arrival at SUN Behavioral ...Medical record information...any interventions/treatments the patient received...Any other pertinent data available ...A signed copy of the Transfer Summary shall be kept by the transferring ...hospital ...A medical record ...established for each individual seeking emergency treatment ...will include ...screening examination ...treatment rendered ...individual's response to treatment ...disposition of case ..."

Hospital document titled "EMTALA Training" stated, " ...A stabilized patient is physically healthy...with no concern of further deterioration after they leave the facility, or ...They are safe to be transported in a ambulance to a hospital ...or ...for psychiatric conditions, stabilized means that patient is protected and prevented from injuring self or others ..."

The hospital document titled "Medical Screening Competency Checklist" stated that staff must "...verbally understand the purpose of the medical screening, correctly obtains and records vital signs, correctly obtains and documents responses to the safety screen, correctly assesses and documents any findings of infectious disease, notifies the Intake Nurse or Nurse Supervisor immediately, correctly assesses and documents any findings of emergency condition, and correctly documents assessment findings for determination of medical clearance of Intake assessment process ..."

B. Staff interview revealed:

1. During an interview with Director of Business Development (DBD) A on 5/20/22 at 2:19 PM, it was stated the transfer form "Patient Request for Transfer or Discharge" should be utilized for any transfer. It was also stated there was no standardized form to document a change in patient disposition, but it is expected that an "Interdisciplinary Note" would be entered into the patient record, explaining the change in disposition. Per DBD A, either a transfer consent or interdisciplinary note should be present in the medical record at the time of disposition.

2. In an interview with Intake Director A on 5/19/22 from 10:49 AM to 11:23 AM, it was stated that if a patient is not admitted or transferred, the process should be to give the patient a referral and establish a safety plan.

3. In an interview with Intake Coordinator A on 5/19/22 from 3:36 PM to 3:56 PM, it was stated that if a patient presented with an acute psychiatric condition, but there are no open beds, the intake staff would still complete the "Intake Assessment". The patient would then either be transferred to another psychiatric facility, another hospital's Emergency department, or will wait in the lobby until a bed is open.

4. In an interview with Registrar A on 5/19/22 from 3:03 to 3:22 PM, it was stated that the Registrar obtains vital signs and documents them on the form "Emergency Medical Screen" and completes a checklist of signs and symptoms with the patient on the "Infection Screening" form. Any vital signs outside of the listed parameters or abnormal signs and symptoms get reported to a Registered Nurse (RN), who will then evaluate the patient. The patient then moves to the Assessment room to have the "Intake Assessment" completed by a clinician, which is either a social worker or nurse.

C. Medical record review revealed:

1. Patient 7
- "Patient Registration Form" was completed by legal guardian (patient was under the age of 18) on 4/1/22 at 9:26 PM. The reason for the visit was documented as, "...cutting and ideations over break up with boyfriend last Saturday night..."
- No evidence of completion of "Infection Screening", "Emergency Medical Screen", or "Intake Assessment".
- No evidence of evaluation of patient condition by a Registered Nurse (RN)
- No evidence of assessment of suicide risk, using Columbia-Suicide Severity Rating Scale (CSSR-S).
- "Interdisciplinary Note" signed on 4/2/22 at 4:55 AM by Intake Coordinator B stated, "...Patient reports she ...self-harmed on her forearms, and experiences SI. Pt showed this therapist her forearms, cuts were up both forearms. Therapist explained that there were no beds available at this time and processed whether patient felt safe going home on a safety plan. Pt stated she could not contract for safety so mother [legal guardian] agreed to take [patient] to [emergency department] for safety ..."
- No documentation of assessment of patient safety for transport, or that consent for transfer was obtained.
- Chief Nursing Officer (CNO) A confirmed on 5/23/22 at 12:35 PM.

2. Patient 12
- Patient arrived on 4/8/22 at 10:09 PM for treatment for substance abuse, but the patient was not admitted by the facility.
- "Emergency Medical Screen" and "Infection Screen" completed on 4/8/22 at 10:30 PM by Registrar A, included abnormal findings on "Infection Screen". No evidence that patient was then evaluated by Registered Nurse (RN).
- No evidence of documentation of disposition of patient, of patient refusal of treatment, or of assessment of patient safety for transport.
- CNO A stated and confirmed on 5/23/22 at 12:40 PM that the patient was sent for medical clearance related to a low heart rate of 48 beats/minute (normal heart rate is 60-100 beats/minute), and also confirmed this transfer was not documented in the patient record.

3. Patient 14
- "Emergency Medical Screen" and "Infection Screen" were completed by Intake Coordinator C on 4/11/22 on 6:57 PM. "Emergency Medical Screen" stated, "The patient has superficial cuts on her left forearm."
- "Interdisciplinary Note" stated, "The patient's mother reports she was given paperwork by child mobile crisis to report here. Currently, we have no open beds for admission, and she is going to Rockford Center to seek help."
- No evidence of evaluation of the patient by an RN, of assessment of suicide risk using CSSR-S, of consent for transfer, of assessment of patient safety for transport, or of staff providing pertinent medical record information to the receiving facility.
- CNO A confirmed on 5/23/22 at 12:42 PM.

4. Patient 15
- "Emergency Medical Screen" and "Infection Screen" stated patient "reported having vomited blood but did not seek treatment" signed by Registrar A on 4/12/22 at 10:19 PM. No evidence of evaluation by an RN.
- "Interdisciplinary Note" signed by Intake Coordinator D at 11:11 PM stated, "Pt reports he was coughing up blood. Pt was sent out for medical clearance."
- No evidence of RN assessment of patient condition, of patient consent for transfer, of assessment of patient safety for transport, or of staff communicating pertinent medical information with the receiving facility.
- Confirmed with CNO A on 5/23/22 at 12:56 PM.

5. Patient 18
- "Intake Assessment" was conducted by RN B and Intake Coordinator E on 4/23/22 at 2:12 AM. Under section for "Level of Care Recommendation", the "Other" category read, "Patient was instructed to go to hospital for medical clearance for an untreated UTI."
- No evidence of patient consent for transfer, of assessment of patient safety for transport, or that pertinent medical information was communicated to the receiving facility. Confirmed with CNO A on 5/23/22 at 12:58 PM.

6. Patient 20
- "Intake Assessment" completed by Intake Coordinator D on 5/9/22 at 10:03 PM contained "Clinical Summary" note stated that the patient was, " ...unstable ...and ...in need of assistance to stabilize ...Presenting factors: I am jittery ...I am nervous ...Insomnia has [not] slept in several days ...Psychotic symptoms present: Hearing ringing in ears and annoying voices that are background noises ...".
- Level of Care recommendation on the "Intake Assessment" was for Inpatient Psychiatric Care, with admitting diagnosis of Major Depressive Disorder, Recurrent Episode, Severe, with Psychotic Features
- No evidence that patient was admitted on 5/9/22.
- No evidence that patient refused treatment, that staff obtained patient refusal of treatment consent, no documentation of transfer consent, no documentation of patient disposition, or of a referral to another hospital.
- A second "Emergency Medical Screen" and "Infection Screen" were completed by Registrar C on 5/10/22 at 10:30 AM. The patient was then admitted to the facility.
- In an interview with CNO A on 5/23/22 at 12:47 PM, it was confirmed and stated the patient was transferred out for medical clearance on 5/9/22, however no evidence of this was documented in the patient record.

7. Patient 24
- Patient record included a "Code Blue/Medical Documentation" form on 5/17/22 at 1:03 PM. An additional document, "Code Blue Summary", stated that the patient's friend brought him to the hospital for treatment related to alcohol use. The patient also had a history of DT's (delirium tremens) from alcohol use. The summary stated that the patient was found in the lobby with seizure-like activity, cyanosis, diminished pulses, not responding to sternal rub or verbal stimuli. Stabilizing treatment was completed, including oxygen, and medications (Narcan and Ativan). 9-1-1 was called, and patient was transported to an acute care hospital.
- No evidence that staff communicated the treatment provided to the patient and any pertinent medical information to the receiving facility. Confirmed with CNO A on 5/23/22 at 12:53 PM.

8. Patient 26
- Presented to the hospital on 2/17/22
- Intake Coordinator A documented in "Interdisciplinary Note" on 2/17/22 at 8:24 PM, that the patient was transported via EMS at 11:56 AM after staff called 9-1-1 due to "psychomotor agitation".
- No medical records were sent with patient to the receiving facility, as documented by Intake Coordinator A on "EMTALA Physician Assessment and Certification" form.
- Confirmed with CNO A on 5/23/22 at 12:55 PM.

Based on policy review, staff interview and review of the hospital's quality improvement data, it was determined that the hospital's governing body and medical staff failed to utilize collected patient transfer data to monitor the safety of patients requiring unexpected or emergent transfer from the facility, thus having the potential to affect 68 out of 68 patients (average daily census during survey) at the hospital. Findings include:

A. Review of policies and procedures revealed:

Hospital policy titled "Organizational Performance Improvement Plan" stated " ...The organizational program, established by the medical staff ...with support and approval from the Governing Body, has the responsibility for monitoring every aspect of patient care ...from the time the patient enters the hospital ...in order to identify and resolve any breakdowns that may result in suboptimal patient care and safety ...Patient care and quality control activities in the following services are monitored, assessed and evaluated: ...Admission/Emergency Services ..."

Hospital policy titled "Emergency Medical Treatment and Active Labor Act" stated, " ...Each incident involving emergency services rendered in individuals at SUN Behavioral will be reviewed by the medical staff of this facility to assure quality and appropriateness of care and transfer ...After the transfer, an Occurrence Report will be completed ...The medical staff provides the mechanism to monitor and evaluate compliance with the transfer policy. One hundred percent of all transfers will be reviewed. The medical staff will recommend actions for problems identified and will document follow-up in the minutes of their meetings ..."

B. Review of hospital Incident log revealed:
1. From 12/22/21 to 6/22/22, a total of 40 occurrence reports were entered for unexpected patient transfers.

C. Review of monthly Performance Improvement Committee meeting minutes from 5/21 to 4/22 (11 meetings) revealed no evidence of review of patient transfers.

D. Review of monthly Medical Executive Meeting minutes from 12/21 to 4/22 (5 meetings) revealed no evidence of patient transfer reviews.

E. Review of quarterly Governing Board Meeting minutes from 5/21 to 5/22 (5 meetings) revealed no evidence of review of patient transfers, including identifying problems and recommending actions.

F. Interview with staff revealed:
1. Medical Director A stated and confirmed on 5/23/22 from 1:47 PM to 2:06 PM that transfers are not being monitored and reviewed by medical staff at this time.
2. Director of Risk/Performance Improvement A confirmed on 5/20/22 at 9:57 AM that transfers are not being tracked and investigated at this time.

Based on medical record review, policy review and staff interview, it was determined that medical record entries for 1 of 32 patients (Patient 20) in the sample, failed to be legible, complete, dated and/or timed. Findings include:

Hospital policy entitled "Completion of Patient Medical Record" stated, " ...Patient Electronic Health Record must be complete as to all assessments, evaluations, treatment plans, orders, notes, discharge notes, discharge plans, and discharge instructions at the time of the patient's discharge ..."

A. Medical Record review revealed:
1. Master Treatment Plan for Patient 20 was not dated, timed, or authenticated by the physician.

This finding was confirmed on 6/23/2022 at 11:02 AM by Chief Executive Officer (CEO) A.

Based on hospital document review, medical record review and staff interview, the hospital staff failed to ensure the medical record was complete to include a consent for treatment, in 1 of 32 patient records reviewed (Patient 31). Findings include:

Hospital document entitled "Medical Staff Rules and Regulations" stated, " ...A condition of admission form, with applicable consent(s) signed by every voluntary patient, the patient's parents, or the patient's legal representative, must be obtained at the time of admission ..."

A. Medical record review for Patient 32 revealed:
1. "Condition of Admission/Consent to Treatment and Information Disclosure" form not signed by patient or staff member.
Confirmed at time of record review with Chief Nursing Officer (CNO) A on 6/23/22 between 9:28 AM and 12:45 PM.