HospitalInspections.org

Based on interviews, record reviews, and policy reviews, it was determined the Hospital failed to comply with the provider agreement as defined in §489.20 and §489.24 to include:
*An appropriate transfer had been implemented prior to discharging 1 of 22 sampled patients (17).
*A thorough and complete discharge had been implemented prior to discharging 2 of 22 sampled juvenile patients (21 and 22).
*A discharge and transfer policy and procedure process for patients diagnosed with a psychiatric illness, who were on an involuntary hold, and who met commitment criteria, did not have a discharge plan that included a transfer to jail or other non-health related facility.
Findings include:

1. The Hospital failed to ensure an appropriate transfer had been implemented prior to discharging 1 of 22 sampled patients (17) who presented to the emergency department (ED) for treatment of suicidal ideation and a plan to commit suicide. Refer to A2407, finding 1.

2. The Hospital failed to ensure a thorough and complete discharge had been implemented prior to discharging 2 of 22 sampled juvenile patients (21 and 22) who presented to the ED for acts involving self-harm and/or suicidal ideation. Refer to A2407, findings 2 and 3.

3. The Hospital failed to ensure their discharge and transfer policy and procedure process for patients diagnosed with a psychiatric illness, who were on an involuntary hold, and who met commitment criteria, did not have a discharge plan that included a transfer to jail or other non-health related facilities when the hospital's behavioral health unit was at capacity. See A2407, finding 3.

30170

A. Based on interview, record review, and policy review, the provider failed to ensure:
*An appropriate transfer had been implemented for 1 of 22 sampled patients (17) who presented to the emergency department (ED) with suicidal ideation and a plan for killing himself.
*A thorough and complete discharge plan had been implemented prior to discharging 2 of 22 sampled juvenile patients (21 and 22) who presented to the ED for acts involving self-harm and/or suicidal ideation.
*A physician's order for admission to the behavioral health unit was completed or documentation explaining the reason one of one sampled juvenile patient (21) that presented to the ED for self-cutting behavior was not admitted for further evaluation.
Findings include:

Surveyor: 20031
1. Review of patient 17's 2/15/17 Transfer Order dated at 12:21 p.m. from IHS (Indian Health Services) to hospital ED revealed:
*Hospital Service: Psychiatry.
*Diagnosis: SI (suicidal ideation).
*Clinical Notes:
-12:25 p.m.: "Dr. [IHS physician's name] called regarding a pt. [patient] he would like to send to [provider's name] for: Suicide Ideation with a plan; the pt. has threatened to harm himself by stabbing himself in the neck with a pencil or hang himself."
"The pt. was taken from Detox to the crisis center. Then from the crisis center to the mental health center at [IHS facility]. Then from the mental health to the urgent clinic at [IHS facility]."
"The pt. was placed on a hold."
"I called and talked to [in-house nurse's name] for psych [provider's psychiatric facility] and gave her the pt. information. [nurse name] said she will need to talk to her supervisor and Dr. [psychiatrist's name]. [nurse's name] said she would call back.
-2:35 p.m.: [in-house nurse name] called to let us know that after discussing the case with her supervisor and psychiatrist, it was decided that they are unable to provide a private room and incompatibility mix."

Review of patient 17's 2/15/17 Petition for Emergency Commitment at 12:00 noon revealed:
*"The patient is suicidal with plan to kill himself by way of hanging or stabbing his neck with a pencil.
*States persistent feelings to kill himself by way of hanging or stabbing himself in the neck.
*Continues to mention he doesn't want to live anymore and wanting to kill himself."

Review of patient 17's 2/15/17 ED electronic medical record revealed:
*He was admitted to the ED at 6:58 p.m.
*He was seen by the physician at 7:22 p.m.

Review of patient 17's 2/15/17 ED nurse's documentation revealed:
*Triage:
-"7:05 p.m.: Brought in by PD [police department].
-7:06 p.m.: Pt [patient] brought in by PD for Psych Eval [psychological evaluation]. Referred from [IHS facility] for thoughts of self-harm.
--Other: Depression.
*History:
-7:08 p.m.: Safety Screening:
--Suicide: Total Score: 7 (for adults in the general population: People with a score of 7 or greater are considered at risk of suicide).
---High Risk - Supervision/psychiatric consult/hospitalization. Institute suicide Precautions per provider order.
---The one-to-one observation constant flow sheet documentation started at 7:45 p.m. and ended at 8:15 p.m.
-Precautions: Suicidal/homicidal ideation."
*Nursing Exam:
-"7:38 p.m.: General: Calm, Alert, Well Developed, Well Nourished.
-Safety: Patient placed in green scrubs, officer at bedside, security watch in place.
*Notes:
-8:32 p.m. Awake, Alert, Oriented x3 [person, place, and time].
-8:34 p.m.: Plan for discharge to Detox. Patient is agreeable to this plan. Patient changed back into his clothes.
-9:17 p.m.: Spoke with [person's name] at Detox. Okay to transfer patient to Detox.
*Disposition:
-9:21 p.m.: Discharge.
--Discharged to: Detox.
--Discharged with security.
--Case management or other services contacted: not applicable."

Review of patient 17's 2/15/17 ED history and physical report revealed:
*"Patient is a 39 year old male presenting as a transfer from [IHS] for a mental health evaluation. He is on a petition for an emergency mental health evaluation. Patient states that he had been feeling depressed for the past couple of days, but he does have a long history of depression. he is currently feeling improved from yesterday, but he still has a plan of suicide. Patients suicide plan is to hang himself and stab himself in the neck. The report that he has been an inpatient at Detox [City/County Detoxification facility name] for the past couple weeks. Patient has not been at Detox for the past 48 hours due to a PTSD [post-traumatic stress disorder] episode, and the patient went to Crisis Care Center and then [IHS name]. He was placed on a hold at [IHS name]. Patient has been off of his mental health medication since September 2016."
*Clinical Impression:
-1. Depression.
-2. Suicidal Ideation.
*Medical Decision Making:
-"2/15/17 labs from [IHS facility] include a positive marijuana, otherwise negative urine drug screen. Urinalysis is negative. CBC [complete blood count] is normal. Chemistry panel was normal. I believe that giving the patient his medication and then transferring him to Crisis Care Center will help him. Crisis Care Center states patient doesn't need to return to them but rather could be discharged to detox where patient has been undergoing treatment plan."
-2/15/17 laboratory test results from [IHS facility]:
--Alcohol Screen: normal/negative.
--UDS (urine drug screening) positive for cannabinoids.
-Disposition: Discharged.
-Condition: Stable."

Review of patient 17's 2/15/17 ED physician's orders revealed:
*7:39 p.m.: "D/C [discontinue] hold; D/C [discharge] to detox."
*8:08 p.m.: "Lamotrigine [depression/anxiety]; Fluoxetine [depression/anxiety]."

2. Review of patient 21's complete electronic ED record revealed:
*She was admitted to the ED on 2/15/17 at 4:03 p.m. accompanied by law enforcement.
*Her birth date was 3/12/02.
*She was fourteen years old.
*Her admitting diagnoses to the ED were:
-Suicidal ideation.
-Suicidal gesture.
-History of psychiatric illness.
*The patient was brought in on a psychiatric hold after cutting her forearms in school during class.

Review of patient 21's 2/15/17 Petition for Emergency Commitment revealed:
*The document had been completed prior to her admission to the ED.
*The specific nature of the danger was suicide.
*She had acknowledged she had thoughts of killing herself, and she had acted on it in the past. Her distraught emotional state of mind indicated the following:
*Evidence of cutting today and there were old scars.
*Pervious history of prescription drug overdose two years ago.
*In conversation today she indicated she cut to feel pain and would continue. The conversation lead to the concern that she would cut again and burn herself again.
*She indicated she also had burned herself in the past.
*She was a special education student and had a self-harm cutting history.

Review of patient 21's 2/15/17 physician's orders on the Emergency Department Record revealed at 5:45 p.m. the attending physician had hand written the following order, "TO WEST ON HOLD" with a diagnosis of suicidal ideation.

Review of patient 21's Emergency Department General Bridge Orders revealed:
*On 2/15/17 at 6:00 p.m. Inpatient Admission had a check mark and indicated an admission to West.
*The diagnosis was suicidal ideation.

Review of patient 21's 2/15/17 physician's history and physical written at 5:51 p.m. revealed:
*The juvenile patient entered the ED at 4:03 p.m.
*Patient was seen by the physician at 4:40 p.m.
*Decision to admit was made at 4:47 p.m.
*Patient was a 14 year old female who presented to the ED for evaluation.
*She had been brought to the ED from school after cutting her left forearm with the metal part of a pencil during a test.
*She stated she had done it, because she was bored and denied depression and suicidal ideation.
*The patient had been cutting herself for the past few days and presented with superficial cuts to both forearms.
*The patient had previously been admitted to [behavior health unit name] once approximately a year ago for a drug overdose.
*Her urine drug screen was negative.
*Her Tylenol level was normal.
*Medical decision making indicated: "Patient is a 14 year old female who present from [county name] on psychiatric hold after cutting her forearms in class. The case was discussed with psychiatry. She will be admitted. The patient will be checked for any elevated Tylenol levels, and a urine drug screen will be obtained. This was discussed with the admitting psychiatrist. Holding orders were written."
*At 5:50 p.m. "psychiatry, case discussed, will admit patient for further evaluation and management."
*Diagnoses: suicidal ideation, suicidal gesture, and history of psychiatric illness.
*At the end of the document the disposition of the patient was admitted at 5:50 p.m. on 2/15/17, and the condition of the patient was stable.

Review of patient 21's 2/15/17 Emergency Room Nurse Documentation revealed:
*At 4:38 p.m. the patient arrived on a hold to the ED in handcuffs.
*Patient reported she had been caught cutting herself. She was smiling, laughing, and joking with staff. Stated to staff, "This is really exciting," and patient stated her intentions for cutting were to give her something to do. Patient stated she was bored and angry.
*At 4:08 p.m. (documented before she arrived in the ED at 4:38 p.m.) She admitted using alcohol approximately three months ago.
*At 4:08 p.m. Precautions implemented were universal.
*At 4:38 p.m. a nursing exam had been completed, and she had superficial cuts to her forearms.
*At 6:46 p.m. she was placed into green scrubs. Urinalysis sent to the lab.
*At 7:30 p.m. "attempted to call report unable to except notified charge rn [registered nurse]."
*At 8:36 p.m. family at bedside.
*At 9:00 p.m. the qualified mental health professional (QMHP) dropped the mental hold, patient left with family smiling and cooperative. Discharged ambulatory to home. Instructions provided written and verbal.

Review of patient 21's 2/15/17 Psychosocial Assessment completed at 6:00 p.m. revealed she:
-Had made suicidal statements, had cut herself at school, and was placed on a mental health hold.
-Had a previous hospitalization on 4/26/16 for a drug overdose.
-Had a history of drug use approximately two months ago.
-Had just started at a new school a few weeks earlier.
-Had talked about Satan on FB (Facebook).
-Did not have many friends.
-Reported she was gay.
-Reported she was not suicidal but had told the school she was.
-Self-mutilated by cutting.
-Had poor insight and judgement.
*Her father had committed suicide and had shot himself in their home.
*The question on the assessment asked "Trauma-past/present (physical, sexual, emotional)." The response documented was: "a lot by her mom, pt [patient] was home when father shot himself."

Review of patient 21's 2/15/17 QMHP evaluation at 8:32 p.m. revealed she:
*Had been involved with outpatient mental health treatment, and she had a previous hospitalization in April 2016 for mental health concerns.
*Had suicidal ideation and suicidal gestures.
*Was: "Cooperative: Presents with a happy/upbeat mood; Denies suicidal ideation; insight/judgment are age appropriate; No evidence of a thought disorder; She has a safe/appropriate discharge plan with her guardian."
*Was not considered to be a danger to herself or others.
*Had depression and ADHD (attention deficit hyperactivity disorder).
*Could benefit from outpatient mental health treatment.
*There was no documentation in the electronic ED record of what the safe plan included as mentioned above.

Review of patient 21's 2/15/17 Discharge Instructions revealed:
*Diagnosis: Self injurious behavior.
*Follow-up within two to three days with your primary care doctor.
*"We have evaluated and treated the patient in the emergency department today due to the patient's urgent medical issue. However, the patient's treatment is not complete until the patient:
-Follow the patient's instructions for the patient's own care at home.
-Take the medications that we have prescribed for the patient.
-Follow-up with the patient's regular physician, or return to the Emergency Department as directed.
-Call or return to the Emergency Department if the patient's condition gets worse, does not go away, or if the patient have any questions about the patient's care or follow-up."
*There was no documentation in the electronic ED record of any prescriptions given to the patient or the patient's family.
*Departure mode: "Walking. Discharged to home."
*There was no documentation who the patient had been discharged with since the patient was only fourteen years of age.
*There was no documentation who had received the discharge instructions other than the juvenile patient.
*There was no documentation regarding outpatient counseling or appointments that had been set-up for the patient, or any suggestions as to what counseling services to contact.
*The patient was discharged from the ED.

3. Review of patient 22's electronic ED record revealed:
*She was admitted to the ED on 2/15/17 at 7:53 p.m.
*Her birth date was 9/17/03.
*She was thirteen years old.
*At 7:53 p.m." pt [patient] crying in triage. Pt has two small cuts to her left wrist from 4 days ago. Mother reports pt does not like her boyfriend and they are getting married. Pt. crying and stating she does not want this person in her life.
At 7:56 p.m. Safety Screening: Suicide: Child Adolescent Suicide Risk: Total score: 2 on 2/15/17 at 8:00 p.m. LOW RISK - Reinforce criticality of follow-up appointments/services with patient and support person(s).
*At 8:01 p.m. Anxious, Crying. Behavior: Presenting Problem: anxiety/panic.
*At 9:15 p.m. Disposition: Discharge. Discharged to home with family. Provided instructions: written, verbal."

Review of patient 22's 2/15/17 physician's history and physical completed at 9:16 p.m. the ED revealed:
*Her blood pressure was 178/101, and her pulse was 113 beats per minute.
*"Patient is a 16 year old female [the patient was 13 years of age] who presented with agitation.
*Tonight she was upset at her mother telling her what to do.
*She made some statement that was concerning to her mother but the mother is unable to recall exactly what the statement was.
*The patient denied suicidal or homicidal ideation.
*She has scratched at her wrists in the past most recently several days ago.
*She stated that she does not like living at home because of her mother's boyfriend."
*There was no investigation or documentation as to the reason she did not like her mother's boyfriend.
* Medical Decision Making: "Her initial blood pressure elevation is likely related to anxiety. A repeat blood pressure is within normal limits for her age. She has no indication for emergency mental health hold. The patient contracts for safety in the emergency department.
*She was evaluated by the needs assessment team.
*Mother and patient are comfortable with discharge and follow-up with a counselor as an outpatient.
*Discussed diagnosis and follow-up with patient and family.
*Discharged in stable condition."

Review of patient 22's 2/15/17 Psychosocial Assessment that was completed at 8:15 p.m. revealed:
*Small cuts to wrist and threatened to do it again.
*There was no current outpatient counseling/treatment, "but mom would look into it."
*"Pt does not like mom's boyfriend who lives w/ [with] them, conflicts w/ them, conflicts w/ mom, close to her little sister."
*She had lived with her mom and her little sister for many years.
*"Pt doesn't like that her mom is going to get married. She wants it to just be her mom and her sister again. Pt has been becoming upset and threatening to harm herself. Mother concerned she may. Parents on board with family counseling, but feel they can keep pt safe."
*"family will follow up w/a [with a] counselor of their choice."
*There was no documentation in the assessment that any health care professional asked the patient why she did not like her mother's boyfriend.
*There was no documentation that names and phone numbers of counselors had been provided to the family.

Review of patient 22's 2/15/17 Discharge Instructions revealed:
*"Follow up with counseling as an outpatient return if you have new concerning symptoms.
*We have evaluated and treated the patient in the emergency department today due to the patient's urgent medical issue. However, the patient's treatment is not complete until the patient:
-Follow the patient's instructions for the patient's own care at home.
-Take the medications that we have prescribed for the patient.
-Follow up with the patient's regular physician, or return to the Emergency Department as directed.
-Call or return to the Emergency Department if the patient's condition gets worse, does not go away, or if the patient have any questions about the patient's care or follow-up.
*Discharged to home. Discharge with family. Departure mode: walking."
*There was no documentation in the electronic ED related to any medications prescribed to the patient.
*There was no documentation regarding scheduled outpatient counseling or other appointments.
*There was no documentation who had received the discharge instructions other than the thirteen year old patient.

4. Interview on 2/22/17 at 8:32 a.m. with the director of the ED and the manager of the ED regarding mental health patients under the age of eighteen revealed:
*Mental health patients under eighteen years of age would not go to jail, because the jail does not house anyone under the age of eighteen.
*Those patients would have been admitted to the hospital for further observation.
*There was no new policy in place for the new procedure that had been implemented by the administration on 2/1/17 in regards to mental health patients seen in the ED.
*The process implemented was to discharge mental health patients on mental health holds to the care of the county jail. Communication would continue through the Transfer Center to find a placement for the patient if continued mental health treatment was required.

B. Based on interview, record review, and policy review, the provider failed to ensure their discharge and transfer policy and procedure for patients diagnosed with a psychiatric illness, who were on an involuntary hold, who met the commitment criteria, did not have a discharge plan that included a transfer to jail or other non-health related facility when the hospital's behavioral health unit was at capacity. Findings include:

1. a. Interview on 2/21/17 at 2:40 p.m. and again on 2/22/17 at 8:32 a.m. with the director of the ED and the manager of the ED regarding mental health patients presenting to the ED revealed:
*It was now their understanding that acute medical care (inpatient tower) did not take care of mental health/psychiatric patients.
-The mental health patient was evaluated for a medical condition (infection, illness, or injury).
-Then the mental health patient might have been admitted to the intensive care unit or patient care unit.
-They would have received one-on-one observation in those units.
*As of 2/1/17 the patients in the tower now had a physiological condition, but not a mental or psychological condition.
*Once a patient was discharged from the ED and off the provider's campus the patient was no longer the provider's responsibility.
*If there was no plan in place the patient might go to jail.
*They did not know the condition of the patient after discharge from the ED.
*They did not know if the patient was safe at the jail. They were no longer responsible, and the patient was now the responsibility of the county.
*When the provider's Transfer Center found a "bed" (place) for the involuntary mental health patient it may be the crisis care center or the city/county alcohol and drug program.
*The Transfer Center was a courtesy provided by the hospital. "It's a courtesy to attempt to find placement for the mental health patient after discharge from the ER [emergency room] to the jail."
*"Mental patients coming to the ED are in a crisis. Going to jail doesn't facilitate their treatment."
*Prior to the new process there had been no safety issues in the patient tower with mental health patients or the provider's staff that they could remember.
*In a meeting with the department directors and/or managers approximately two weeks before 2/1/17, they had been told there was going to be a new process and criteria for behavioral health admission.
*They were given no new policy or new guidelines to follow for this new process.
*They had been told by administration "We have been told by legal [the provider's general counsel] this is going to happen as of 2/1/17."
*Administration did not put any formal procedure or plan in place prior to the change on 2/1/17.
*The basic plan would have been to discharge the patient on a mental health hold from the ED to the jail if there was no post discharge plan in place. The QMHP (qualified mental health professional) would have evaluated the patient in jail if needed.
*They had not completed any tracking or trending of the new process since it was initiated.
*They had done a group and one-on-one notification of the new process for mental health patients on a hold, but they agreed there were still employees that had not been notified of the new process.
*They had not tracked the training with the ED employees as the process had happened very quickly.

b. Interview on 2/22/17 at 8:32 a.m. with the director of the ED revealed upon notice from administration and the provider's general counsel she had created their own behavioral health capacity communication plan. Review of that undated plan revealed:
*When Behavioral Health is at capacity:
-The on call Transfer Center then called [city name] dispatch to inform law enforcement that they were full and would not accept additional behavioral health patients.
*When a bed opened at Behavioral Health:
-If no patients were holding in the [hospital name] inpatient/ED area, the on call Transfer Center called dispatch to inquire if law enforcement was holding any behavioral health patients and notified them they now had open beds.
*If a new behavioral health patient arrived while the behavioral health unit was at capacity, the on call Transfer Center initiated the checklist of Behavioral Health patients.
*Transfer Center Process/Communication when the behavioral health unit was at capacity:
-If you received a call from a clinic in [city name] or elsewhere and there was no bed available for the patient state that, "Behavioral Health is at full capacity and they will need to call local law enforcement to have them take custody of the patient."

c. Interview on 2/22/17 at 8:00 a.m. with the director and clinical nurse of Behavioral West unit revealed:
*They were made aware of the new process at a 12/7/16 meeting with the provider's legal department.
*They had a department meeting on 1/18/17 to let staff know about the changes in the new process. Not all of the staff were notified, because some had been on leave.
-Review of the 1/18/17 department meeting minutes revealed:
"2. Change in Admissions - February 1 there will be a change in patients that will be admitted to [psychiatric facility]. We will be restricting dementia and diagnosed autistic patients. We are also working toward no overflow to the towers [inpatient rooms at the main hospital]. The affected community will be notified by letters regarding these changes."
*Adolescents were on a one-to-one floor. If a suicidal ideation adolescent patient needed admission from ED and there was no bed at the psychiatric hospital:
-They would have let the Transfer Center and ED know there was no room.
-Transfer Center would have notified the county.
-QMHP would evaluate the ED physician's decisions.
-The QMHP made the "safe plan."
-The ED physicians could request a consult from one of the psychiatrists at the psychiatric hospital.

d. Interview on 2/22/17 at 9:20 a.m. with the medical director of the emergency department revealed:
*Late last Fall 2016 he had heard word that the provider wanted criteria for a mental health admission to the hospital. The problem appeared to have been space for mental health patients in the hospital.
*He thought it was a financial/administrative perspective of "How can we detour those patients who were intoxicated from admission to the hospital."
*Financial concerns made the decision to put the process in place.
*Administration did not involve those staff who were going to be directly involved in the process, i.e. ED staff. Administration stated "We have been told by legal (the provider's general counsel) this is going to happen as of 2/1/17. The process was birthed through individuals not involved in direct patient care."
*He understood the new process was:
-ED would admit the patients.
*Involuntary holds would typically come into the ED.
-With an involuntary hold a QMHP would have twenty-four hours to evaluate the patient for emergency commitment or removal of the hold when in the ED.
-While in the ED "they (patients) are the responsibility of the hospital."
-The county QMHP had to either certify the hold or remove the hold.
-If the hold was removed by the QMHP the facility's Transfer Center would attempt to get the patient to another treatment facility.
*"The crisis care center absorbs much of the mental health patients now."
*His department was given a verbal process from administration, but he had never seen anything written down.
*"Mental health issues are medical issues. Any patient coming to the ED is an emergency. Mental health has been separated out from a medical condition."

e. Interview on 2/22/17 at 10:30 a.m. with the provider's interim president revealed:
*"We started this process in accordance with state law."
*When (behavioral health center) was full, those mental health patients on a mental health hold would have been transferred to the jail.
-We would like the county to take responsibility for the patient.
*We could no longer take the risk of safety for the patients and staff in the patient tower.
-There had been no safety incidents that had happened in the tower to either mental health patients or to the staff.
*"When we are full the county needs to take responsibility."
*When the patient was discharged from the ED the county was responsible for that patient.
*The QMHP determined the patient was either committed (admitted) or not (hold removed).
*While still in the hospital the county made the determination where the mental health patient would go.
*"We offered the Transfer Center service to assist the county with placement of the mental health patient.
*What we are doing is in accordance with state law."

f. Interview on 2/22/17 at 11:10 a.m. with the QMHP revealed:
*She was an employee of the county.
*She did not have a contract with the hospital nor was she credentialed by the hospital.
*She had been told she would evaluate all patients who had been delivered to the ED by local law enforcement. The county was responsible for:
-A QMHP.
-A hearing officer.
-Transportation to another facility.
*She stated an emergency commitment hold would have been admitting the patient to a psychiatric medical facility. The closest regional (in area) psychiatric hospital would have been the local hospital.
*If the patient did not meet the mental health guidelines according to state law she would have removed the patient from the hold, and they would have been released.
*It was not her decision where the patient would have been transported to after the removal of the hold and released from ED.
*The Transfer Center would work with authorities to transfer the patient to another acute care facility.
*She did not determine the disposition of the patient. She determined if they met the criteria of an involuntary hold or removal of the hold.
*Prior to October 2016 all mental health patients went to the psychiatric unit and received QMHP evaluations. After October 2016 all psychological evaluations went through the ED.
*She had been told the change was due to a lot of mental health patients in the ED were discharged within twenty-four hours and were not admitted.
*It was her understanding it was a financial decision made by administration.

g. Interview on 2/22/17 at 11:30 a.m. with the director of the Transfer Center revealed:
*The Transfer Center was part of the hospital.
*All ED patients and inpatients went through the Transfer Center.
*If the patient presented to the ED involuntarily the QMHP would evaluate that patient.
*The health unit clerk placed a request for a bed in the system to see if a bed was available or unavailable.
-If no bed was available the voluntary mental health patients would have been held in the ED until a treatment could have been initiated.
*If the patient had been evaluated by the QMHP the county was responsible to get the patient continued care if needed.
*When the mental health patient was turned over to the county they would have had the decision to transport to another acute care facility or to have taken the patient back to jail.
-She revealed "I think the patient is safe in jail. But I don't think they are getting the treatment they need."
*The Transfer Center only dealt with continued acute patient treatment to other providers.
*The Transfer Center was directed by the provider's general counsel to contact the county to "ask what they want to do with the patient."
*"The patient in the ED was the responsibility of the hospital, and mental health issues were considered a medical emergency."
*There was no policy for the new process, it was only a process change.
*The provider's legal department had created the 1/18/17 procedural checklist and flow chart.
-Review of the above dated flow chart revealed:
-Patient arrives on a hold, or hold was placed = NO.
-Case management and Transfer Center would assist with community resources and D/C (discharge).
-Review of the above dated checklist of behavioral health patients revealed:
-1. Verify that there was no bed at Behavioral Health.
-2. If no bed was available at Behavioral Health unit then call law enforcement.
-Ask "would you like us to attempt to find another facility to transfer the patient to or would you like to take custody of the patient."
-3. Start calling other facilities that law enforcement had agreed to transport to.
-4. If another facility had accepted the patient then contact law enforcement.
-If no accepting facility contact law enforcement to take custody of the patient.
-5. If the county was unwilling to take the patient or there were other issues the hospital coordinator would be contacted, and decisions would be made by the administrator on-call.

h. Interview on 2/22/17 at 12:30 p.m. with the MSW (masters in social work) revealed:
*In the ED the QMHP would make the decision to see if the temporary hold should remain in place or if it could be removed.
*The QMHP's job was not to make the decision of the disposition of those patients.
*It was the hospital's responsibility to find a disposition for the patient.
*If our facility was full the patients would have either gone to the crisis center or to another provider.
*There should be a safety plan or contract in place to keep the patient safe.

i. Interview on 2/23/17 at 8:00 a.m. with the county sheriff and chief deputy regarding mental health patients seen in the hospital ED revealed:
*The sheriff's department had received a letter from the local hospital dated 1/23/17 prior to the initiation of the new process at the hospital. The new process was related to mental health patients brought to the ED on a mental health hold or placed on a mental health hold during the ED visit.
*The sheriff thought the change in the process had been related to availability of hospital beds, staffing issues, and behavioral health was not profitable for the hospital.
*Jail was not the appropriate place for those individuals with mental health conditions.
*He stated a mental health emergency should have been treated just like a medical condition emergency.
*There needed to have been more bed availability for mental health patients.
*He felt as though there would have been a delay in treatment for those mental health patients if they were admitted to the jail. Jail was not the place for individuals with mental health conditions.
*There were no twenty-four hour nursing services available at the jail. A nurse was available from 6:00 a.m. until 10:00 p.m. at night.
*The hospital's attorney had come to the jail on January 20, 2017 to inform the sheriff about the new process scheduled to have been initiated on February 1, 2017.
*The new process was mental health patients who were on mental health holds would have been