HospitalInspections.org

Based on record review and interview, the hospital failed to ensure appropriate transfer of a patient to a higher level of care for 1 (Patient #9) of 21 patient records reviewed. This failed practice had the potential to result in delayed care and possible deterioration of health due to the lack of information provided to the receiving facility.

Findings:

The surveyors reviewed a policy titled "Transfer Policy", which read in part:

"If a patient is to be transferred for medical necessity the following guidelines must be followed:
A physician certification that the risks of transferring the patient are outweighed by the potential benefits;
The receiving hospital must give acceptance in advance. The acceptance must be documented in the medical record;
Copies of the medical record, x-rays and laboratory tests will accompany the patient when transferred."

Patient #9

Patient #9 arrived at the facility's ED on 07/24/22 at 2:46 am with the chief complaint of suicide attempt by hanging. The patient was brought by law enforcement for medical examination and clearance prior to evaluation at a facility with psychiatric care (the facility does not provide psych services.)

The surveyors reviewed the patient's record and noted the following:

The patient was given a psychiatric evaluation via telemedicine at approximately 3:00 am and an order of protective custody was initiated.
At 3:03 am, Staff D documented a local tribal law enforcement agency would take custody of the patient as he was identified as a tribal member.
at 4:23 am, Staff F documented review of imaging results and stated patient was "medically cleared".
At 4:27 am, Staff F documented "(name of patient) is medically cleared for transportation, incarceration, and psychiatric evaluation and inpatient care."
At 4:30 am, Staff D documented "Patient dc'd to (tribal law enforcement) custody to be evaluated at (tribal hospital)."

The patient was subsequently taken by tribal law enforcement to an IHS hospital for psychiatric evaluation and treatment. There was no documentation of physician certification regarding the risks/benefits with transfer. There was no documentation of the receiving hospital accepting the patient for evaluation/treatment. There was no documentation to support the patient's records were sent to the receiving facility.
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On 08/16/22 at 1:45 pm, the surveyors met with Staff E and asked why the patient was discharged to law enforcement and not transferred to the receiving facility. Staff E stated the patient should have been transferred to the hospital and the physician responsible for the discharge was new (review of credentialing files indicated the physician had been granted privileges about two weeks prior to the incident.) Staff E also stated report should always be called to the receiving facility.

On 08/17/22 at 10:50 am, the surveyors met with Staff D, who was involved with the care of the patient. Staff D stated tribal law enforcement "took over patient" and informed him/her as soon as the patient was medically cleared, he/she would transport the patient to IHS facility. Staff D interpreted this to mean a transfer was not necessary. The surveyors asked how the receiving facility would have knowledge of the patient's condition prior to arrival, Staff D stated they wouldn't know of the patient's condition and now it makes sense that a transfer should have been done.