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Based on a review of medical records, facility staff and complainant interviews, and a review of the facility's policies, it was determined the facility failed to comply with 42 CFR 489.24, as a result one patient (P#1) out of 20 sampled was improperly transferred to another facility.

Cross refer to C-2409, as it relates to the facility's failure to provide P#1 with an appropriate transfer.

Based on a review of medical records, interviews, documentation records, Emergency Department (ED) central log, and a review of policies and procedures, it was determined the facility failed to provide a safe transfer for one patient (P), (P#1) of 25 patients. P#1 presented to the facility's Emergency Department with an emergency medical condition on 9/19/2021 but was not provided a safe transfer to a subsequent facility.

Findings included:

A review of the facility's Emergency Department (ED) central log revealed that P#1 was admitted at the facility's ED on 9/19/21 at 1:38 p.m. on a 1013 (involuntary detention due to probability of self-harm and inability to care for self).

A review of P#1 medical record revealed P#1 presented to the facility's ED with chief complaints of suicidal thoughts, anxiety and delusions, hallucinations, drank excessive volume of Vodka per day, and has not taken psychiatric medications for two years. P#1 stated he wanted to kill himself by riding his bike into traffic. ED Registered Nurse (RN) triaged the patient at a level 2 (Acuity Level 2: A condition that indicated the patient was at risk and requires immediate medical attention). The Physical Exam in the ED was noted to be normal; P #1 was alert but with poor hygiene. A nursing note dated 9/19/21 at 3:09 p.m. documented P#1 was placed on continuous one on one supervision, checks performed every 15 minutes, and P#1 was given paper scrubs and placed in direct sight of the nurse's station.

On 9/21/21 at 1:15 p.m. record review revealed Unit Clerk LL faxed over P #1's medical record to a few local facilities in search of placement, including the facility where P #1 was transferred. At 10:25 p.m. a nursing note documented a staff member at the partner facility reported that all psychiatric facilities in the area were at full capacity. P#1 was reassessed and was not in any form of distress.

On 9/27/21 at 3:30 p.m. P #1 was discharged; and the condition at departure was described as improved. A handwritten note in the medical record indicated P #1 was discharged at 3:20 p.m. to Deputy custody per Affidavit to Apprehend. The note was signed by RN AA, Emergency Department Coordinator.

An Order to Apprehend dated 9/27/21 attention to any Peace Officer of said county noted, you are commanded to take the above-named individual (P#1) into to custody who can be found at the facility under investigation and deliver to the address of a crisis stabilization unit for an examination as prescribed by law.

Review of policy titled "Patient Transfers", policy number: none, effective date: 8/25/20, next review date: 8/25/22 revealed it was the policy of the facility to establish guidelines for the appropriate transfer of patients to another facility. The purpose of the policy was to ensure continuity of care and to promote communication among all members of the healthcare team and receiving facility. The policy applied to Patient Care Services, Emergency Medical Services, and the Medical Staff via the Clinical Policy Manual. The policy defined "Transfer" as the movement (including the discharge) of an individual outside a hospital's facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the hospital; but did not include such a movement of an individual who had been declared dead or left the facility without the permission of any such person.
Further review of the policy revealed that the facility transferred a patient to another facility when:

1. The transferring facility provided medical treatment within its capacity that minimized the risks to the patient's health, and in the case of woman in labor, the health of the unborn child.
2. The receiving facility had available space and qualified personnel for the treatment of the patient and had agreed to the transfer of the patient and to provide appropriate medical treatment.
3. The transferring facility sent to the receiving facility copies of medical records related to the medical condition of the patient that was available at the time of transfer.
4. The transfer was done by qualified personnel and transportation with effective equipment, as required, to include the use of necessary and medically appropriate life support measures during transfer.

Further review of the policy indicated procedures the facility followed when transferring a patient to another facility:

A. The transferring physician notified the receiving physician of the impending transfer.
B. Prior to the transfer, the physician wrote an order for transfer that included the receiving physician and facility.
C. The transferring physician completed the Patient's Request/Refusal/Consent form to include the risks, benefits, alternatives, and signature sections of the form.
D. The facility obtained Consent for the transfer with the appropriate signatures of the patient or the person acting on the patient's behalf.
E. The facility nurse contacted the potential receiving facility to inquire room availability.
F. When the room became available, the nurse contacted the receiving facility and gave the patient report to the appropriate personnel. The nurse documented the name of the receiving personnel on the Patient's Request/Refusal/Consent form.


During an interview with Emergency Department Clerk LL on 10/13/20 at 9:49 a.m. in the administrative office, Clerk LL said she remembered P #1 because he was in the ED for many days. Clerk LL said she remembered patients who remained in the ED because she got to see them every day. Clerk LL said the only role she played in the patient's stay was she faxed his papers to the local psychiatric facilities and the patient was placed on a 1013. Clerk LL stated only nurses or doctors could call the judge. Clerk LL said when the patients were placed on hold waiting for placement, her job was limited to faxing their medical record to hospitals in the region and once she received confirmation, she placed it in their chart. She said the confirmation remained in the patient's chart until one of the facilities called and said they had a bed. Clerk LL said the local psychiatric facility communicated with the ED personnel daily to let them know if a bed was available somewhere.

During an interview with Compliance Officer (CO PP) on 10/13/20 at 10:15 a.m. a.m. in the administrative office, CO PP said she remembered the case regarding P #1 because the ED Unit Coordinator (RN AA) called to inform her about a patient that the Deputy just picked up from the ED. CO PP said many people in the area came to the facility to get help; she said they followed procedure by placing the patients on the state board (Gcals), waiting for placement. CO PP said they contacted a local psychiatric facility and the local psychiatric facility assisted in finding placement for the patients. They also sent requests to different facilities in the region to expedite the process. CO PP stated they were not a psychiatric hospital. She said they could not release these patients for liability because they could go out there and commit suicide. They tried to help them get the help they needed by accepting help from the Judge.

During an interview with the ED unit Coordinator (RN AA) on 10/13/21 at 11:15 a.m., RN AA stated she remembered P #1, she said the patient was brought to the ED due to suicidal thoughts. RN AA stated they did not offer psychiatric service at the facility, but they contracted the service with another provider that did tele-service to psych patients (digital consults for psychiatric services) whenever they had them. RN AA said after consulting with their provider, the ED physician placed P #1 on a 1013 because the patient was still suicidal and that it was not safe to discharge P #1. RN AA stated P#1 was reassessed every day to maintain or discontinue his 1013. RN AA said after being in the ED for a week, the Judge stepped in and was able to find placement for P #1.

RN AA could not remember if someone at the facility called the judge or if the Judge just happened to call in the ED. RN AA said it was customary for other people in the community to call the judge to help find placement for a loved one, they had in the ED for a period. RN AA said after P #1 was discharged, she did speak with RN SS at the receiving facility that called to request more medical information related to P #1. RN AA said she asked for a signed release form before she could release more documents, but the facility never submitted such document. RN AA said P #1 was discharged to the County Judge, she further stated that once the P #1 or any patient was discharged to the Judge, they did not have any other responsibility as far as placement was concerned and that it was up to the judge to send P #1 wherever she saw fit to continue treatment.

A phone interview with Nurse Practitioner (NP) RR took place on 10/13/21 at 11:57 a.m., NP RR said she was a provider at Facility #2. P #1 arrived at her facility as a 1013 escorted by the deputy sheriff. NP RR said the Admission Nurse (RN SS) on duty received a call from RN AA (Facility #1) and asked if they could accept P #1. RN SS said no because they were at maximum capacity. NP RR said the facility got the Judge involved and sent P#1 ' s medical information to the Judge to bypass the proper way that patients got accepted by other facilities. NP RR stated the facility did that all the time, when they said no to a transfer. Facility #1 would call the Judge and force them to accept the transfer. NP RR said the notion the facility claimed P #1 was discharged was not true because they delivered P #1 to the Judge as a 1013. You just could not discharge a patient as a 1013 said NP RR. NP RR said the ED had already spoken to their admission and was told they did not have a bed at that time. NP RR stated P #1 was imposed on them by force.

A phone interview with RN SS was conducted on 10/13/21 at 3:30 p.m. RN SS stated she worked as an intake nurse at Facility #2 where P #1 was transferred. RN SS stated the day P #1 arrived at her facility, The ED Coordinator (RN AA) called the facility and asked if they could accept P #1. RN SS said she answered no because they did not have a bed and because of staffing that day. RN SS said a couple hours after she spoke with RN AA, they received a call from the deputy to inform them that P #1 was on his way. RN SS said she was told that the Judge was just basically taking over the case. The ED from Facility #1 said they were done, the Judge took over the case, she was sending the patient over to them. RN SS said "ok", she said she was not going to argue with a judge because she was afraid that things would escalate. RN SS said the judge called her. RN SS stated it was intimidating to have a judge call about a case. RN SS said once the judge called, they did not have any choice but to accept P #1. Facility #2 admitted the P#1 voluntarily, not as a 1013.

During an interview with Registered Nurse (RN) MM on 10/14/21 at 10:10 a.m. in the administrative room, RN MM stated she remembered P#1 because he was in the ED for many days, and she had charted on him. She said she did not discharge him because P #1 was not in a wheelchair, he was mobile and very much independent. RN MM said the County Judge often called the ED and talked to the charge nurse to find out if they had mental health patients in need of placement. RN MM said if the judge issued an order of apprehension, the unit secretary would take the paperwork to her and let her know that the deputy sheriff was on his way to pick up a patient and the patient would then be discharged to the deputy to wherever the judge ordered him to take the patient. RN MM said it was quite common for psychiatric patients to come to the ED because they did not have a place to go. These patients would remain in a little bed bolted to the floor with no TV, no light for days because there was no placement for them, especially true for those without insurance. RN MM said the Judge would intervene to help find placement and free the ED from being bombarded with patients that were not getting the help they need and just simply occupied space in the ED. RN MM reiterated that it was routine for the judge to call the facility's ED to help find a bed for these patients at a psychiatric facility.

During a phone interview with ED Physician QQ on 10/14/21 at 11:20 a.m. Medical Doctor (MD) QQ stated if patients with mental health needs came in the ED they evaluated these patients to determine if they had medical conditions. Psychiatric facility ' s evaluated mental health patients remotely. In the case of P #1 MD QQ stated, they medically screened him and made sure there was nothing medically wrong. We made a risk and benefits decision on whether the patient was appropriate to go for inpatient care or outpatient care. MD QQ said they made that decision along with their contracted psychiatric tele-medicine services. MD QQ said having the mental health patients stressed the ED even more and having patients they could not find placement for compromised the care they were able to provide. Other issue with psych patients being in the ED for days was, these patients were one on one supervision and as a result there were not enough staff to support their needs and the needs of other patients. MD QQ explained the ED staff were stretched to the limit when they had three patients laying down in the ED for days; he said they were in a tight situation such that patient care was negatively affected. He stated they would ask the staff to reach out to the judge to help find relief and helped the patients in general. MD QQ stated the judge was always a mental health advocate and they had reached out to her in the past for any help they could get.

Summary:

There was no accepting physician obtained. There was no facility that agreed to take the patient. There was no transfer form on the record. The risks and benefits were not discussed with the patient. The patient was not stable and was discharged to the custody of police to be taken to the facility that did not have room to accept the patient. The patient was discharged in an unstable condition and required further psychiatric care and emergent placement for suicidal ideation.