HospitalInspections.org

Based on review of the facility's plan of correction, review of facility policy, medical record review, and interview, the facility failed to appropriately transfer three patients (#8, #9, and #11) of six patients reviewed.

The findings included:

Please refer to A-2409 for failing to appropriately transfer.

Based on review of the facility's Plan of Correction, medical record review, review of facility policy, and interview, the facility failed to appropriately transfer three patients (#8, #9, #11) of six patients reviewed.

The findings included:

Review of the facility's Plan of Correction (correction date alleging compliance effective June 26, 2013), revealed, "The current transfer process for all patients will be applied to involuntarily committed patients ...The process is as follows ...All transfers of patients under the involuntary commitment process will require the following ...Physician documentation of an order for mental health crisis evaluation ...Documentation that any medical treatment available at (facility) has been provided in order to minimize the risk to the individual's health ...Transfer Order completed by a physician or a qualified medical person in consultation with a physician, and signed by the physician, which includes a certification that the benefits outweigh the risks ...Documentation that the patient has been informed, to the extent possible, of the risks and benefits of transfer in the Patient Consent to Transfer form ...A Patient Transfer Checklist ...nursing personnel or mental health crisis personnel will contact an appropriate facility to confirm acceptance and arrange for the transfer ...Nursing personnel will ensure that the Patient Transfer Order, Patient Consent to Transfer form, and Patient Transfer Checklist are complete and that appropriate medical records are sent with the patient ...Education will be provided to Emergency Department physicians and staff, including psychiatric staff and behavioral health consultants, regarding the policy changes and the process for transfers of psychiatric and involuntarily committed patients ...will conduct audits of the medical records of all involuntarily committed patients who are transferred to psychiatric facilities for a minimum of six months; monitoring will continue ...to ensure 100% compliance ...audit process began May 21, 2013 ..."

Patient #8 presented to the facility's Emergency Room on June 27, 2013.
Medical record review of a Clinician History of Present Illness dated June 27, 2013, at 2:33 p.m., revealed, " ...is hallucinating auditory hallucinations. Patient reports hearing voices telling (patient) to 'cut wrist' ...Here voluntarily for a psychiatric evaluation ...Primary Diagnosis Hallucinosis ...Suicidal thoughts ..."

Medical record review of a physician order dated June 27, 2013, at 3:07 p.m., revealed, "Notify Crisis to see patient once stat (without delay)."
Medical record review of a Nurse Practitioner's note dated June 27, 2013, at 3:08 p.m., revealed, "Disposition decision is discharge. Disposition is transfer. Transfer to Psychiatric Facility crisis to eval (evaluate) and place ..."

Medical record review of a physician's note dated June 27, 2013, at 3:42 p.m., revealed, " ...as the supervising staff physician (Doctor of Osteopathy - D.O. - #1) concur with the final disposition."

Medical record review of a Crisis Intervention and Consultation Assessment Form dated June 27, 2013, at 3:46 p.m., revealed, " ...Acuity: Psychiatric Emergency ...presenting problem ...reports A/H (auditory hallucinations) telling (patient) to cut on (patient's) wrists and kill (self) ...reports H/O (history of) cutting self ...when a voice told (patient) to do so ...even if the voice was not telling (patient) to do so ...still feels suicidal ...Impulse Control Minimal ...Provisional Diagnostic Summary ...Major Depressive Disorder, severe, recurrent w/psychotic feat (with psychotic features) ...Conclusion As safety plan, ct (client) agrees to tx (treatment) at the (psychiatric stabilization facility) ...and agrees to stay min 72 h (minimum of 72 hours) ...will need TNCare Transport (state funded transportation) ...cannot contract for safety at home ...Disposition Psychiatric Hospitalization: Crisis Stabilization Unit ..."

Medical record review of a Mobile Crisis Team Plan of Action dated June 27, 2013, at 3:46 p.m., revealed, " ...Crisis Stabilization Unit Admit ...No accepting facility has been determined at this time ..." Continued review revealed, "If accepted: Psychiatric Facility: (blank) Name of Admitting Physician: (blank) Name of Admissions Contact: (blank) Time Accepted: (blank) ...If not yet accept: Current Facility that has been contacted: (Crisis Stabilization Unit) ..."

Medical record review of a nurse's note dated July 27, 2013, at 10:25 p.m., revealed, " ...Disposition status is discharge. Discharge to: (psychiatric stabilization facility) ...left department ..."

Medical record review revealed no documentation regarding a transfer form, reason for transfer, risks and/or benefits, or the patient's consent to transfer.

Interview with the Risk Manager on July 9, 2013, at 2:48 p.m., in her office, and in the presence of the Emergency Department's Clinical Leader, revealed a stable patient would be discharged for treatment on an outpatient basis, the Crisis Stabilization Unit was an inpatient facility, and confirmed the facility failed to provide an appropriate transfer for Patient #8 on June 27, 2013.

Patient #9 presented to the facility's Emergency Room on June 27, 2013, at 12:02 a.m.

Medical record review of a Clinician History of Present Illness dated June 27, 2013, revealed, " ...brought in by EMS (Emergency Medical Services) for self-inflicted laceration to left wrist ...states that father and (patient's) wife are apparently close to death and (patient) would like to 'join them.' Pt (patient) would not answer ...questions about being suicidal or homicidal ...laceration caused by a knife ...wound will require surgical closure ..."

Medical record review of a physician order dated June 27, 2013, at 3:21 a.m., revealed, "Notify Crisis to see patient once stat (without delay)."

Medical record review of a physician's progress note dated June 27, 2013, at 4:42 a.m., revealed, "Re-evaluation: Pt with suicide attempt ...states wants to die. Will have Crisis eval (evaluate)."

Medical record review of a Crisis Intervention and Consultation Assessment Form dated June 27, 2013, revealed, " ...Acuity ...Psychiatric emergency ...Time consult stated ...(5:05 a.m.) ...did admit to cutting self ...feeling like has no reason to live ...Was impulsive action not planned ...intoxicated on presentation ...Reasons To Live Cannot think of any ...Disposition ...Psychiatric Hospitalization: Involuntary ..."
Medical record review of a Certificate of Need for Emergency Involuntary Admission dated June 27, 2013, at 5:05 a.m., revealed, " ...am a Qualified Mental Health Professional ...designated by the ...Commissioner as a mandatory pre-screening agent ...reports depression, hopelessness - in last year also ...drank alcohol for years ...case beer combined with ? gallon of liquor daily ...AND ...substantial likelihood that such harm will occur unless the person is placed under involuntary treatment ...AND ...needs tx (treatment) ...started on psychotropic medications for major depression and alcohol dependence ...AND ...already hurt self ...may be danger to others - has reported hx (history) murder legal charge - been in prison ..."
Medical record review of a Patient Transfer Order (Medical Doctor - M.D. #1) dated June 27, 2013, revealed, " ...Transfer medically indicated ..."

Medical record review of a Patient Consent to Transfer signed by the patient and dated June 27, 2013, at 5:50 p.m., revealed the reason for the transfer and the benefits/risks of the transfer were not identified.

Medical record review of an undated, untimed Patient Transfer Checklist (a form required by facility policy and the facility's plan of correction) revealed, " ...If this is a medically indicated transfer: Complete the 'Consent to Transfer' Form and Complete the 'Patient Transfer Order' Form ..."

Medical record review of a nurse's note dated June 28, 2013, at 12:02 a.m., revealed, " ...Transfer to (Psychiatric Hospital)...Patient/caregiver received a copy of the transfer sheet ...which provides detailed information about the transfer ...Patient left department ..."
Medical record review revealed incomplete documentation of the required transfer forms and no documentation regarding the risks and/or benefits of the transfer.

Review of facility Policy Number: HVNC_DT-685-029-PO most recently reviewed ad/or revised in May 2013, revealed, " ...Specific guidelines will be followed in the management of patients with acute psychiatric illness, including ...suicidal patients, who are being ...dispositioned from the Emergency Department ...The Emergency Department physician, after examining the patient, will initiate appropriate consults with the Crisis Team ...along with the Crisis Team will also initiate transfers to psychiatric facilities, if indicated, and as appropriate under EMTALA (Emergency Medical Treatment and Labor Act). Nursing/clerical staff will assist in contacting consultants and completing appropriate transfer forms ...Involuntary committal process ...Complete the EMTALA documentation - send with patient ..."

Review of facility Policy Number: HVMC-DT-685-167-PO dated May 28, 2013, revealed, " ...For patients to who EMTALA applies and who have an unstable emergency medical condition (EMC) ...as defined by EMTALA, staff will follow the transfer process herein to ensure compliance ...If a patient's EMC cannot be stabilized ...within the Capability and Capacity of (facility), the Hospital should arrange an Appropriate Transfer as defined under EMTALA. Transfer requirements apply to patients who have an EMC which has not been Stabilized, including psychiatric emergencies whether or not the patient is involuntarily committed ...Transfer of an EMTALA patient with an EMC which has not been Stablized requires ...the receiving facility has agreed to accept the transfer ...Documentation ...will include all applicable EMTALA forms patient transfer checklist, patient transfer order, patient transfer consent with risks, and benefits ...Disposition documented by the physician (or qualified medical personnel) will not 'Transfer' ...date and time of the transfer request and the name and title of the person accepting the transfer ...certification of the risks and benefits of transfer (if not included on EMTALA transfer form) ...Movement of a patient between departments of the Hospital is not a Transfer ..."

Interview with an Emergency Department Clinical Leader on July 9, 2013, at 3:45 p.m., in the Risk Manager's office, confirmed Patient #9 was inappropriately transferred on June 28, 2013.

Patient #11 presented to the facility's Emergency Room on July 2, 2013.

Medical record review of a Clinician History of Present Illness dated July 2, 2013, at 4:38 p.m., revealed, "Pt (patient) states ...struck (patient's) mother and sister ...Mother states pt is threatening to harm ...self as well as ...sister and mother ...Primary Diagnosis ...Suicidal thoughts ..."

Medical record review of a physician order dated July 2, 2013, at 4:48 p.m., revealed, "Notify Crisis to see patient once stat."

Medical record review of a Crisis Intervention and Consultation Assessment Form dated July 2, 2013, revealed, " ...Acuity ...Psychiatric Emergency ...became upset at home today and pushed/kicked sister and attempted to push mother down stairs ...Threatened to stab self last week ...threatened to grab steering wheel and wreck car today ...emotionally unstable/impulsive ...broke pool stick last wk (week) in order to stab self ...Plan ...Psychiatric Hospitalization ...Involuntary ...currently danger to self/others due to lack of impulse control ...unable to reliably contract for safety/unstable ..."

Medical record review revealed no documentation regarding a Certificate of Need for Emergency Involuntary Admission.

Medical record review of a physician's note (Doctor of Osteopathy #2) dated July 2, 2013, at 6:46 p.m., revealed, "Disposition decision is transfer ...to Psychiatric Facility AS ARRANGED BY CRISIS ...Patient/caregiver received a copy of the transfer sheet ...which provides detailed information about the transfer. Reason for transfer discussed with patient. The primary reason given was: SUICIDAL IDEATIO (suicidal ideation). Condition at discharge - stable ..."

Medical record review of a Patient Transfer Order signed by Medical Doctor #2 dated July 2, 2013, at 11:48 p.m., revealed, " ...Transfer medically indicated ...The receiving hospital/physician have agreed to accept this patient in transfer ..." Continued review revealed the time of the agreement was not documented. Continued review revealed a section of the form titled "To Be Completed by Transferring Hospital Staff" was blank.

Medical record review of a Patient Consent to Transfer dated July 2, 2013, at 11:49 p.m., revealed a section of the form titled "Physician Certification for Transfer was blank. Continued review revealed a specific benefit of transfer was not identified and included, " ...benefits include: Evaluation and Treatment ..."

Medical record review of a nurse's note dated July 3, 2013, at 12:00 a.m., revealed, " ...Disposition status is transfer ...(Psychiatric Hospital) ...Patient/caregiver received a copy of the transfer sheet ...which provides detailed information about the transfer ...will be transferred via law enforcement ...left department ..."

Interview with the Risk Manager on July 9, 2013, at 11:50 a.m., in her office, confirmed the facility failed to provide an appropriate transfer for Patient #11 on July 2, 2013, and confirmed the facility failed to implement the Plan of Correction alleging compliance effective June 26, 2013.