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Based on interview and record review, the hospital failed to provide an appropriate transfer to another medical facility to 1 of 1 patient (Patient #1) that presented in the Hospital A emergency department (ED) on 01/12/17 with an emergency psychiatric condition and presented to Hospital B emergency department on 01/14/17.

Cross Reference to:

1) A 2409 - An appropriate transfer/discharge - §489.24(e) (1) and (2) Failure to Provide Appropriate Transfer/Discharge






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Based on record review and interview, the hospital failed to make an appropriate transfer, in that,1 of 1 patient (Patient #1) had an emergency psychiatric medical condition that was not stabilized by the hospital, but the patient was handcuffed, shackled, restained to a backboard and transported to Hospital B by the police via an ambulance service. The hospital failed to send a copy of Patient #1's medical record, prepare a MOT (memorandum of transfer), call the receiving hospital for acceptance of the patient, complete a nurse to nurse report and complete a physician to physician report per their policy.

Findings include:

Review of the medical record for Patient #1, who was diagnosed for Xanax withdrawal, altered mental status, insomnia upon admission. Patient #1 was actively hallucinating (seeing people and bugs that were not present). Patient #1's condition escalated during the next day with police having to be called twice to help control the patient. Hospital C, a psychiatric hospital, declined to accept the patient due to the patient not being "medically stable".

Review of nurses notes:
9:48 PM (nurse progress note) Personnel #19 at Hospital C refused the transfer of patient for not being medically stable...9:52 PM (nurse progress note) Patient #1 is swinging at the police officers, 6 officers are trying to hold him down on 2 point restraints with a football helmet for patient's safety. 10:01 PM Order by Personnel #9 for Unconditional Discharge. 10:22 PM Called ambulance service for transport. Will be arriving in 25-30 min. Patient will be transported with the police officers, on handcuffs and on a backboard.

Notes from Security Officer Report:
"1/14/17 5:50 PM until 11:00 PM duration 5 hours and 10 minutes...Police arrived at 8:00 PM...He then tried to swing at an officer...handcuffs on him...applied the leg shackles...six police officers to hold...This went on for hours and they soon put a helmet on the patient...decision was finally made that the patient was medically cleared and discharged. At this time the Irving PD would APOWW the patient and sent him to Hospital B..."

An interview with Personnel #9 on 05/02/17, Personnel #9 stated the patient had psychiatric needs that they could not provide to the patient. Personnel #9 stated that the patient was on Observation status and there was so much going on they missed changing him over to Inpatient status. Personnel #9 stated that this patient was too dangerous to keep.

Review of the policy "Patient Care: Psychiatric Emergencies" Policy # PC 16.120, Last Revised/Reviewed 4/12.
"If the patient is going to a hospital, the house supervisor will make every effort to complete the typical transfer paperwork, but at a minimum will copy the current medical record to send along with the police officer. 3. The house supervisor will notify the facility (if hospital) as to the events that occurred and fax over the records to the appropriate department. 4. The House Supervisor will make every effort to connect the primary physician with the receiving hospital for a physician to physician handoff ...When possible, every effort will be made to handle the Warrantless Apprehension as if it were a normal transfer, complete with an MOT, a receiving physician, and hospital."