HospitalInspections.org

Based on policy review, closed medical record review, staff and physician interviews, and Transfer Center call log review, the hospital failed to comply with 42 CFR 489.24.

The Findings include:

~cross refer to 489.24(e)(1)-(2) Appropriate Transfer Tag A2409

Based on policy review, closed medical record review, staff and physician interviews, and Transfer Center call log review, the hospital's dedicated emergency department (DED) failed to ensure an appropriate transfer by failing to: ensure the physician documented a summary of the risks and benefits of transfer for 3 of 6 sampled DED patients that were transferred with an emergency medical condition (EMC) (#34, #37, and #35); ensure the physician certified that the benefits of transfer outweighed the risks to the patient at the time of transfer for 4 of 6 sampled DED patients that were transferred with an EMC (#34, #35, #33, and #38); and ensure a written patient request for transfer that included documentation that the patient was aware of the risks and benefits of transfer for 1 of 2 sampled DED patients that requested transfer and were transferred with an EMC (#35).

The findings include:

Review of the hospital's policy, "Transfer of Patients from (Hospital A)", revised 08/20/2010, revealed, "POLICY: ...No patient is transferred from (Hospital A) until: ...D. Copies of applicable medical records accompany the patient to the receiving facility. E. The physician has documented the risks and benefits of the transfer and has fully explained those to the patient and/or family....PURPOSE: To comply with Emergency Medical Treatment and Labor ACT (EMTALA) GUIDELINES: ...E. The transferring physician explains the patient's condition and the risks and benefits of transfer to the patient or the patient's legally authorized agent....F. A Physician Certification Statement (PCS) is completed by a Physician, Doctor of Osteopathy, Registered Nurse, Physician Assistant, Registered Nurse Practitioner, Case Manager or Discharge Planner....I. A copy of the medical record including laboratory reports, radiographic studies, orders and consents, as applicable, accompanies the patient....L. The transferring physician signs the PCS form indicating the reason for transfer and the patient's condition at the time of transfer....M. The above procedure also applies to transfers that are the result of a request form from a patient or his/her legal representative. The PCS form indicates that the transfer is at the request of the patient or his/her legal representative, and the patient or guardian signs the transfer form authorizing the transfer...."

1. Closed medical record review for Patient #34 revealed a 41 year-old male that presented to Hospital A's DED via EMS (emergency medical services) on 02/28/2011 at 1351 with a head injury after ejection from a propane truck in a motor vehicle accident. Record review revealed the patient was triaged as a "Code Trauma" at 1353 and was immediately taken to the resuscitation room. Record review revealed vital signs at 1353 were: Blood Pressure 129/85, heart rate 77, respirations 21, temperature 97.3, oxygen saturation 91%. Record review revealed the patient was seen by Physician #1 upon arrival to the DED. Record review revealed Physician #1 consulted Physician #2 (Neuro/Trauma Surgeon) at 1358. Record review revealed the patient had CT (computerized tomography) scans of the head, spine, and body, trauma protocol lab set, chest x-ray and pelvic x-ray at 1407. Review of the results of the CT scans and x-rays revealed a sub-arachnoid hemorrhage was seen in the bilateral frontal lobes of the brain. Further review of the results revealed the patient had a left clavicle fracture, fractures of lumbar spine transverse processes at L (lumbar) 1-5. Review of the nursing documentation revealed at 1440" (Physician #2) spoke with (Hospital B) trauma services who will accept patient through ED". Record review revealed the patient was intubated at 1505. Record review revealed the patient received Phenytoin Sodium (steroid to decrease brain swelling/prevent seizures) 1 gram IVP (intravenous push) at 1550 and a Tylenol suppository at 1652 for temperature of 38 degrees Celsius (elevated). Review of the nurses' documentation revealed, "1720 (Trauma Surgeon) at bedside speaking with patient's wife about patient's CT results and plan of care...." Record review revealed documentation of a PCS Certificate of Transfer/Informal Refusal of Transfer form that contained 3 sections (A, B, and C) dated 02/28/2011. Review of the form revealed, "A. IMMEDIATE INTERHOSPITAL TRANSPORT 1. Specialized care needed for this patient, not available at this institution...(checked) Neurologist/Neurosurgeon 2. The patient may require an emergency procedure/level of care beyond that available at this institution. The anticipated procedure is: (checked) Other (handwritten) Neuro/ICU (neurological intensive care unit) 3. The patient's needs are best met by the following team: An appropriate certified vehicle operator and : (checked) Critical Care Paramedic & Specialty Care Transport B. Type of Transport (none of the boxes are checked) C. ...2. Reason for transfer (checked) Equipment or services not available at this facility. 3. Mode of transport (checked) ALS (Advanced Life Support) Ambulance 4. Personnel accompanying patient (checked) ALS personnel 5. Transfer acceptance: Facility (Hospital B) ED Bed Availability (checked ) Y (yes) Accepting Physician (Physician #3-Hospital B) Person obtaining acceptance (Physician #1 [ED Attending] 6. Patient/legal representative consent to transfer: (handwritten) Pt intubated, unable to sign (Physician #1) request transfer". Review revealed a signature line for the patient/legal representative was blank. Review of the bottom of the form revealed "Summary of Risks of Transfer: Possible equipment failure (not checked), Possible vehicle accident (not checked) Summary of Benefits of transfer: Closer to home/family (not checked). I hereby certify that based on the information, available to me at the time of transfer, the patient is stable and/or the medical benefits expected from transfer to another facility outweigh the risks to the individual, and it the case of labor, to the unborn child. The patient/legal representative understands the risks and benefits of the transfer (signed by a registered nurse)." Further review of the transfer form revealed no physician's signature. Review of the transfer form and the patient's medical record revealed no documentation of the risks and benefits of the transfer or that the risks and benefits of transfer were explained to the patient's legal representative. Further review of the transfer form and the patient's medical record revealed no documentation that a physician certified that the benefits of transfer outweighed the risks to the patient at the time of transfer. Record review revealed the patient was transferred to Hospital B at 1840 via ALS (advanced life support) ambulance with ALS personnel accompanying the patient.

Review of Patient #34's open medical record from Hospital B (printed on 03/04/2011 and received by surveyor on 03/08/2011) revealed the patient arrived at Hospital B on 02/28/2011 at 2004 and was taken to the Surgical Intensive Care Unit (SICU) at 2115. Review of a neurosurgery consult dictated by Physician #13 (neurosurgery resident) revealed, "Pt with exam....At this time, no need for urgent neurosurgical intervention. Will reexamine pt....if pt extubated soon and formal reads negative, may be able to clear clinically. In regards to multiple lumbar...fx (fracture), no need for neurosurgical intervention, but keep pt in full spine precautions o/n (overnight) for attending review in am. Pt discussed w/ (Physician #14 - attending), who agrees w/ the above plan, and will be staffed w/ (Physician #15 - attending)." Review of a physician's progress note dated 03/04/2011 at 0911 revealed, "24 Hour Events: Transferred from SICU to floor....(alert and oriented) to person only....Deformity L(eft) clavicle with edema....Pt is a 41 yo (year old) male involved in a MVC sustaining intraparenchymal hemorrhage, L clavicle fx, and R(ight) L1-L4 fx's....Pain controlled with PO Percocet, IV for breakthrough....Dispo(sition): Foor....Most likely will need TBI (traumatic brain injury) rehab(ilitation).

Interview on 03/02/2011 at 1600 with Physician #2 (Neuro/Trauma Surgeon) revealed the physician was called to the DED on 02/18/2011 for consultation on Patient #34. Interview revealed, "there were no surgical ICU beds available. This patient needed a neurosurgical ICU bed." Interview further revealed, "My expectation is that the ED physician is to complete the transfer forms, including explaining and documenting risks and benefits. I am a consultant to the ED physician". Further interview revealed, "I spoke with his wife about the results of his CT scan and told her we didn't have a bed here."

Interview requested on 03/03/2011 at 1000 with Physician #1 (DED physician attending) for Patient #37. Physician was not available for interview.

Interview on 03/02/2011 at 1600 with the Interim Director/Nurse Manager for Hospital A's DED revealed, "the physician certification can be signed by the nurse. It must be countersigned by the physician." Interview further revealed, "(Physician #2) took over from the ED physician. He should have signed the certification form." Interview confirmed there were no risks and benefits of the transfer documented for Patient #34. Interview further confirmed there was no available documentation that a physician certified that the benefits of transfer outweighed the risks to the patient at the time of transfer.

Interview on 03/03/2011 at 1230 with the Interim Medical Director of Hospital A's DED (Physician #4) revealed ED physicians are responsible for all transfers. Interview revealed "it is the ED physician's responsibility to have a discussion with the patient and family regarding the transfer. Risks and benefits are discussed....It is very dependent upon the situation....We discuss benefits as well....We explain why something can't be done here." Interview further revealed, "the physician certification of transfer should always be signed by the physician....I sign it when I talk to the receiving physician....If there is a long delay, we should re-certify with the receiving physician (prior to transfer)." Interview confirmed there were no risks and benefits of the transfer documented for Patient #34. Interview further confirmed there was no available documentation that a physician certified that the benefits of transfer outweighed the risks to the patient at the time of transfer.

2. Closed record review of Patient #37 revealed a 54 year-old female that presented to Hospital A's DED via EMS on 02/16/2011 at 1326, after falling at home, with a chief complaint of right arm, rib and shoulder pain. Record review revealed the patient was triaged at 1326 with acuity level of 3 (on a scale of 1 to 5, with 1 being the most acute). Record review revealed a pain assessment was done at 1330, with documentation of severity score of 10 of 10 (on a scale of 1 to 10, with 10 being the highest). Record review revealed the patient was seen by Physician #1 at 1400. Record review revealed the patient received Dilaudid (narcotic pain medication) 1 mg (milligram) IV and Zofran (anti-nausea medication) 4 mg IV at 1444. Record review revealed the patient had an x-ray of her right forearm. Review of x-ray results revealed, "comminuted fracture of the right proximal humerus". Review of Physician #1's documentation at 1400 revealed, "...pt and family request transfer to (Hospital C). Calling to accept...." Documentation of vital signs at 2056, prior to discharge, revealed blood pressure 121/76, heart rate 68, respirations 18, 100% oxygen saturation and pain severity 9 of 10 (on a scale of 1 to 10, with 10 being the highest). Record review revealed documentation of a Physician Certification Statement for Ambulance Transportation form that contained 3 sections (I, II and III) dated 02/16/2011. Review of the form revealed, "Section I- Patient Information Patient Transported from: (Hospital A) Patient Transported To: (Hospital C) Section II- Ambulance Transportation is medically necessary only if other means of transporation are contraindicated or would be potentially harmful to the patient...Moderate to severe pain on movement (checked). Other (handwritten) humerus fracture, sling in place...." Record review revealed documentation of a Certificate of Transfer/Informal Refusal of Transfer form dated 02/16/2011. Review of the form revealed, "... 2. Reason for Transfer: Patient/legal representative initiated request for transfer (checked)... 5. Transfer acceptance: Facility: (Hospital C) Accepting Physician: (Physician #5 at Hospital C) Accepting Staff: Orthopedic Surgery ... 6. Patient/legal representative consent to transfer: I have been informed of and understand the risks and benefits of the transfer as summarized below. I consent to the transfer. (checked) (Signed by patient's spouse and witnessed by a registered nurse). ...Summary of Risks of Transfer: Possible equipment failure (checked), Possible vehicle accident (checked) Other: (blank) Summary of Benefits of transfer: Closer to home/family (not checked). Other (blank).... I hereby certify that based on the information available to me at the time of transfer the patient is stable and/or the medical benefits expected from transfer to another facility outweigh the risks to the individual... The patient/legal representative understands the risks and benefits of the transfer (signed by Physician #1 on 02/16/2011 at 1928)." Record review revealed no documentation of patient specific risks and benefits of the transfer. Record review revealed the patient was transferred to Hospital C at 2057 via ambulance.

Review of Patient #37's closed medical record from Hospital C revealed the patient was directly admitted to an inpatient unit on 02/16/2011 at 2230. Review of the history and physical dictated by Physician #5 on 02/17/2011 at 0733 revealed "...(Patient #37) is a 54 year-old female who fell while at home and injured her right proximal humerus. She was originally seen at (Hospital A)...Given the amount of pain that she was having she was unable to be discharged to home from the Emergency Department and requested admission. ...IMPRESSION: Comminuted fracture of right proximal humerus...." Review of the discharge summary dictated 02/25/2011 revealed Patient #37 was discharged from Hospital C after having surgical right shoulder reconstruction on 02/20/2011.

Interview requested on 03/03/2011 at 1000 with Physician #1 (DED physician attending) for Patient #37. Physician was not available for interview.

Interview on 03/03/2011 at 1230 with Physician #4, the Interim Medical Director of Hospital A's DED, revealed ED physicians are responsible for all transfers. Interview revealed "it is the ED physician's responsibility to have a discussion with the patient and family regarding the transfer. Risks and benefits are discussed....It is very dependent upon the situation....Risks should be specific to the patient." Interview confirmed there were no patient specific risks and benefits of the transfer documented for Patient #37.

Interview on 03/02/2011 at 1600 with the Interim Director/Nurse Manager for Hospital A's DED confirmed there were no specific patient risks and benefits of the transfer documented for Patient #37.




22563

3. Medical record review for Patient #35 revealed a 47 year-old female that presented to the DED via EMS (Emergency Medical Services) on 02/28/2011 at 1142 with complaints of shortness of breath (SOB) and chest pain. Record review revealed EMS staff administered Aspirin (analgesic/anti-inflammatory) by mouth and Nitroglycerin (antianginal/vasodilator)sublingually en route to the hospital. Record review revealed the patient's past medical history included bronchitis, COPD (chronic obstructive pulmonary disease), coronary artery disease, non-insulin dependent diabetes mellitus, hypertension, and sleep apnea. Record review revealed the patient weighed 156.63 kilograms. Review of the triage nurse's assessment documented at 1146 revealed the patient complained of "ache, constant" chest pain, which she rated 5 of 10 in severity (on a scale of 0-10 with 10 being the most severe pain). Review of the triage nurse's assessment documented at 1149 revealed, "Chief Complaint: SOB....Initial Triage Acuity: 2 (on a scale of 1 to 5, with 1 being the most acute)...Note: Pt (patient) arrives via (EMS) from home with c/o (complaints of) SOB x several days. Pt also reports 15 lb (pound) weight gain over short period of time. EMS reports Rhales bilaterally. Pt initial sats (oxygen saturation) 80% on room air. Pt placed on NRB (non rebreather oxygen mask) in route. Sats increased to 99%...." Record review revealed documentation the patient was placed on a NRB mask in the DED at 1152 and her oxygen saturation level was 100%. Record review revealed documentation at 1153 the patient's vital signs were assessed. Record review revealed "ED protocol" physician's orders, documented at 1215, for a chest x-ray, CBC (complete blood count) lab, CK (cardiac enzymes) lab, CKMB (cardiac isoenzymes) lab, Troponin lab, Pro-Brain Natriuretic Peptide lab, Basic Metabolic Panel lab, and EKG (electrocardiogram). Record review revealed documentation at 1225 that Physician #1 (DED attending physician) evaluated the patient. Review of Physician #1's documentation on the Emergency Physician Record at 1225 revealed the patient had a history of congestive heart failure (CHF) and had recently been hospitalized at Hospital B. Further review of the Emergency Physician Record revealed the patient complained of left sided chest discomfort, that started at 0800, that the patient rated at 3 out of 10 in severity at the time of the physician's assessment. Review of Physician #1's Physical Exam documentation revealed the patient was in moderate distress, had bilateral + 3 pedal edema, and had bilateral "decreased air movement", rales, and rhonchi. Record review revealed at 1232 Physician #1 ordered additional lab tests, including arterial blood gases, PT/PTT (prothrombin/partial thromboplastin time), Digoxin level, ISTAT Chem 8 and (blood chemistries). Record review revealed the patient was given the following medications per physician's orders: Furosemide (diuretic) 80 mg intravenously at 1244 and Nitroglycerine paste 1 inch topically. Review of nurse's notes at 1348 revealed the patient rated her chest pain as a 0 of 10 (no pain). Review of the record revealed documentation that Physician #1 reviewed lab, chest x-ray, and EKG results. Review of Physician #1's documentation on the Emergency Physician Record revealed, "D/C from (Hospital B) last Thurs (02/24/2011). There for 6 weeks for CHF....Wants to go back to (Hospital B)....Discussed with...(Hospital B) transfer cntr (center) (at) 1245....(check box checked) Counseled patient/family regarding: (check box checked) Rx given....CLINICAL IMPRESSION: Dyspnea - acute....Congestive Heart Failure...." Further review of the Emergency Physician Record revealed Physician #1 documented notes regarding calls made to Hospital B to arrange the patient's transfer in the center margin of the record (difficult to read). Review of the notes in the center margin revealed, "...(phone numbers for Hospital B)....(Physician #6 - a cardiology Fellow physician at Hospital B) - they have a bed for her....Adult thru ED....D/W (discussed with) (Physician #3 - an ED physician at Hospital B) ED at (Hospital B). Await call from (illegible)." Review of nurse's notes revealed the following: "1353:....Patient alert...no distress, vital signs rechecked, Wait explained to patient....Waiting for bed assignment....1357:...Report given to (name of nurse at Hospital B)....1412:...Spoke with (name) at (Hospital B) ground transport. ETA 2 hours....1512:...Patient alert...no distress, Patient remains stable, vital signs rechecked, Wait explained to patient....1514:...Severity Score: 0/10 - Pain Free....1622...Note: (Hospital B) here for transport. Pt reports understanding. NAD (no acute distress) noted...." Record review revealed the nurse reassessed the patient's vital signs and pain level (still 0/10) at 1617. Record review revealed the patient was transferred to Hospital B at 1625 via ambulance with Hospital B's transport staff. Record review revealed no documentation of a Physician Certification Statement (PCS) form. Further record review revealed no documentation of the risks and benefits of the transfer or that the risks and benefits of transfer were explained to the patient. Record review revealed no documentation of a written patient request for transfer that included documentation that the patient was aware of the risks and benefits of transfer. Record review revealed no documentation that a physician certified that the benefits of transfer outweighed the risks to the patient at the time of transfer.

Review of Hospital B's Transfer Center call log dated 02/28/2011 revealed documentation that Physician #1 spoke with Physicians #6 and #3 at Hospital B and requested to transfer the patient to them. Review revealed documentation at 1332 that both physicians at Hospital B accepted the patient's transfer.

Review of Patient #35's open medical record from Hospital B (printed on 03/04/2011 and received by surveyor on 03/08/2011) revealed the patient arrived at Hospital B on 02/28/2011 and was admitted to Unit 3AD at 1829. Record review revealed copy of the patient's medical record from Hospital A had been sent to Hospital B. Review of the copy of records sent with the patient revealed no documentation that a physician certified that the benefits of transfer outweighed the risks to the patient at the time of transfer. Review of Hospital B's admission physician's History and Physical dated 02/28/2011 at 1848 revealed, "Assessment and Recommendation....SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC, CONGESTIVE HEART FAILURE (CHF)...." Review of physician progress notes dated 03/04/2011 at 1040 revealed, "...She was admitted with volume overload of unclear origin....Was net negative 4 L(iters) on lasix (diuretic) gtt (drip) and this was converted to intermittent dosing on 3/2....continue daily weights, telemetry...."

Interview requested on 03/03/2011 at 1000 with Physician #1 (DED physician attending) for Patient #35. Physician was not available for interview.

Interview on 03/03/2011 at 1230 with the Interim Medical Director of Hospital A's DED (Physician #4) revealed ED physicians are responsible for all transfers. Interview revealed, "It is the ED physician's responsibility to have a discussion with the patient and family regarding the transfer. Risks and benefits are discussed....It is very dependent upon the situation....should be specific to the patient's condition....It's patient dependent....If it's a patient requested transfer, we stabilize the patient before transfer. The patient signs the form...." Further interview revealed a Physician Certification Statement (PCS) form should be completed and signed by the physician at the time of transfer. Interview revealed Physician #4 reviewed the patient's medical record. Interview revealed, "It looks like (Physician #1) called (Hospital B) and obtained a bed." Interview confirmed there was no available documentation of the risks and benefits of the transfer, the risks and benefits of transfer were explained to the patient, the patient's written request for transfer, or that a physician certified that the benefits of transfer outweighed the risks to the patient at the time of transfer.

Interview on 03/03/2011 at 1340 with the Interim Chief Nursing Officer revealed Physician Certification Statement (PCS) form must be completed and signed by the physician at the time of transfer. Interview revealed the form should include documentation of the risks and benefits of the transfer, documentation the risks and benefits of transfer were explained to the patient, documentation of the patient's written request for transfer (if it was a patient request), and documentation that a physician certified that the benefits of transfer outweighed the risks to the patient at the time of transfer. Interview revealed the physician sometimes documents information regarding a transfer in other parts of the medical record. Interview confirmed there was no available documentation in Patient #35's medical record of the risks and benefits of the transfer, the risks and benefits of transfer were explained to the patient, the patient's written request for transfer, or that a physician certified that the benefits of transfer outweighed the risks to the patient at the time of transfer.

4. Medical record review for Patient #33 revealed a 26 year-old male that presented to the DED via EMS (Emergency Medical Services) on 01/30/2011 at 1821 for a psychiatric evaluation with complaints of increased agitation. Record review revealed the triage nurse assessed the patient at 1826 and noted a past medical history of depression and bipolar disorder. Record review revealed Physician #7 (DED physician) evaluated the patient at 1826. Record review revealed physician's orders for complete blood count lab, comprehensive metabolic panel lab, medial blood alcohol lab, urine drug screen lab, urinalysis lab, magnesium level lab, psychiatric precautions, and psychiatric evaluation. Review of Physician #7's documentation on the Emergency Physician Record timed 1826 revealed, "Chief Complaint: agitated....(increased) today, but for quite some time....continues in ED....current/associated complaints: angry/frustrated/agitated/hostile....PAST HISTORY: prior records reviewed....psychiatric problems: depression, bipolar disorder, schizophrenia...hypertension...other: Bronchitis / Turettes...." Further review of Physician #7's documentation revealed the physician examined the patient and reviewed lab results. Review of Physician 7's documentation revealed no documentation of the physician's "clinical impression" of the patient or of the patient's disposition. Review of nurse's notes at 1912 revealed, "Psychiatric Precautions....Subjective: pt (patient) threatens to kill others, pt. threatens to kill self. Objective: disheveled appearance, no eye contact, threatened bodily harm to self. Assessment: potential threat to self, cooperative at this time...." Record review revealed documentation at 2138 that Physician #8 (psychiatrist) evaluated the patient. Review of Physician #8's note dictated at 2202 revealed, "...presents in the emergency department, stating that he called the ambulance to be brought in for evaluation because 'I didn't know what to do.'...The patient had been residing at a group home, but apparently he decided to leave the group home, and after he left, the group home did no want to take him back because the patient apparently had been making threatening comments toward residents at the facility....The patient states that he feels 'a little depressed,'...denies any suicidal or homicidal thoughts or plans....Previous records indicate that he has a history of stabbing himself in his right arm in June 2010, although the patient had previously indicated that this was not really a suicide attempt on his part....No blood alcohol was detected in the emergency department and the urine toxicology screen is positive only for cannabis....He apparently has a psychiatrist at (outpatient treatment facility) and has been prescribed Abilify and Remeron, but admits to being noncompliant on these medications....The patient has a history of hypertension, although it does not appear that he is on any antihypertensive medications, and his current blood pressure measurements are within normal limits....The patient is currently homeless and on the streets....The patient relates auditory hallucinations....also states that he sees visual hallucinations....At times he is noted to be rambling with some thought disorganization. His insight and judgment appear to be impaired....DIAGNOSES: Schizoaffective disorder....Polysubstance dependence....TREATMENT PLAN: 1. I will fill out involuntary commitment paperwork and divert the patient to an appropriate mental health facility for further evaluation and treatment. There are currently no beds available at (Hospital A's inpatient behavioral health unit)...." Review of "Affidavit and Petition for Involuntary Commitment" papers dated 01/30/2011 and signed by Physician #8 revealed, "I...believe that the respondent is a proper subject for involuntary commitment...and is...(check box checked) 1. mentally ill and dangerous to self or others or mentally ill and in need of treatment in order to prevent further disability or deterioration that would predictably result in dangerousness....The facts upon which this opinion is based are as follows: Respondent relates auditory and visual hallucinations and is manifesting poor insight and judgement. He needs stabilization in a controlled environment...." Record review revealed documentation that nursing staff called 5 different hospitals in an effort to find placement for the patient before they sent a request to Hospital D (State psychiatric hospital) on 01/31/2011, at which time the patient was placed on a waiting list for admission. Review of nurse's notes dated 02/01/2011 at 1007, "Received telephone call from (name) at (Hospital D). Pt has been accepted...." Record review revealed documentation of a PCS Certificate of Transfer/Informal Refusal of Transfer form. Review of the form revealed, "C. ...2. Reason for transfer (checked) Equipment or services not available at this facility. 3. Mode of transport (checked) Automobile 4. Personnel accompanying patient (checked) Law Enforcement 5. Transfer acceptance: Facility (Hospital D - State psychiatric hospital) Bed Availability (checked ) Y (yes) Accepting Physician (Physician #9-Hospital D) Person obtaining acceptance (name of ED psychiatric nurse) 6. Patient/legal representative consent to transfer: (handwritten) Invol(untary) commit(ment)....Departure date/time: 2-1-11 (at) 1335...." Review of the bottom of the PCS form revealed, "Summary of Risks of Transfer: (checked) Possible equipment failure, (checked) Possible vehicle accident, fall, injury, death....Summary of Benefits of transfer: Mood Stabilization, med(ication) mgt (management), assessment....I hereby certify that based on the information, available to me at the time of transfer, the patient is stable and/or the medical benefits expected from transfer to another facility outweigh the risks to the individual, and it the case of labor, to the unborn child. The patient/legal representative understands the risks and benefits of the transfer (signed by Physician #8) Date: 1-30-11 (2 days before the patient was transferred)." Further record review revealed documentation that the last time the patient was seen by a physician at Hospital A prior to transport was on 01/31/2011 at 1820, when he was seen by Physician #10 (psychiatrist) (1 day before the patient was transferred). Review of Physician #10's note on 01/31/2011 at 1820 revealed, "f/u (follow up)...Pt cont(inues) to be hopeless about situation....Denies current SI/HI (suicidal and homicidal ideations), but not able to contract for safety....cont(inue) meds / Diversion process." Record review revealed documentation on 02/01/2011 at 1335 the patient was transferred to Hospital D accompanied by law enforcement staff. Record review revealed no documentation that a physician certified that the benefits of transfer outweighed the risks to the patient at the time of transfer (was done 2 days before the patient was transferred).

Review of Patient #33's closed medical record from Hospital D revealed the patient arrived at Hospital D on 02/01/2011 at 1615. Review of the physician's "Initial Psychiatric Assessment" dictated on 02/02/2011 at 1314 revealed, "...a 26 year-old African-American male who presented with suicidal ideations because he stated that he needed help finding a new place to live....Patient will be admitted for further evaluation and treatment...." Record review revealed the patient was discharged to a group home on 02/21/2011 with a diagnosis of schizophrenia and with arrangements for outpatient treatment.

Telephone interview on 03/03/2011 at 1400 with Physician #8 (psychiatrist) revealed, "After an evaluation, disposition is made. If it's a transfer, I let the psychiatric nursing staff know of the need to transfer....I sign some paperwork for the transfe