HospitalInspections.org

Based on a review of the medical record, facility documentation, and interviews
Hospital A failed to meet the following requirements of an appropriate transfer:
No memorandum of transfer was signed by the transferring physician;
No evidence of Consent and Request with Risks and Benefits was completed;
No evidence of a Physician Assessment and Certification was completed;
No evidence of a Hospital Patient Transfer Form or appropriate patient records related to the patient's emergency medical condition were sent;
No evidence the transferring hospital provided medical treatment within its capacity to minimize the risks to an individual's health who was experiencing a psychiatric emergency medical condition;
And no evidence the receiving facility had available space and qualified personnel or had agreed to accept the transfer of the individual and provide appropriate medical treatment for 1 of 20 patients (Patient #1).

Facility A failed to follow its policy when Patient #1 was not transferred properly to Facility B with a completed MOT (memorandum of transfer), transfer request or acceptance by Facility B who had an acute psychiatric emergency medical condition.

Findings included:
A review of Patient #1's medical record review at Facility A found in a document titled "ED Provider Notes" on page 1 revealed the following, " ...Chief Complaint: Suicide Attempt (Pt presents via EMS/Springtown PD for c/o suicide attempt. According to report, pt's father received a text message from her stating she was going to end her life/told him 'Goodbye' prompting an EMS [Emergency Medical Serives] call. Pt took an unknown amount of her prescribed Sertraline 100mg. EMS states pt had seizure at 2:15 AM.) Accompanied by: Police ..."

Patient #1's medical record review at Facility A contained a document titled "Behavioral Health Intake Assessment Summary", by LMSW (Staff #25) on page 15 that stated, "Patient presented to the Emergency Department at (Facility A) accompanied by Police on NOED (Notice of Emergency Detention)/ APOWW (Apprehension by Police Officer Without a Warrant).
Chief complaint presenting concerns as stated by patient (precipitating event(s)/circumstances within the past 24-72 hours prompting request for assessment): ...
Patient presents to MED ED (medical emergency department) status INVOL (involuntary) with police due to alleged suicide attempt. Per police, patient reportedly ingested unknown amount of sertraline and then texted father "goodbye."... police will be staying with patient in MED ED until medically cleared and transferring her to (Hospital B) for further evaluation. BHCC (behavioral health crisis clinician) to remain available should new needs arise."

Patient #1's medical record review at Facility A contained a "Disposition" documented by LMSW, Staff #25, on page 16 that stated:
"Collateral Contacted: No
Recommendation: Inpatient BH (behavioral health)
Reviewed with: [Facility A's Staff #22]
Treatment Disposition: Inpatient BH
Status: WD (warrant of detention)/APOWW (Apprehension by Police Officer Without a Warrant)/Mental illness warrant (MIW)
Transfer Center Notification Order Placed? No"

A documentation review of the EMS (emergency medical systems) run sheet on page 2 stated that Patient #1 presented to Facility A's Emergency Department (ED) accompanied by Springtown Police Department (SPD) (Other Staff #30) in handcuffs (due to refusal of care) via EMS on a stretcher on 05/21/2023 at 2:22 AM after a suicide attempt.

A documentation review of Facility A's 'Direct Admit and Transfer Policy', last reviewed by Facility A and became effective on 06/02/2023, states on page 1,
"3.2 Transfers and Direct Admissions for Behavioral Health Services. Transfers and
direct admissions of patients that require behavioral health services will be routed
through the BHTC (behavioral health transfer coordinator)." Facility A failed to provide an appropriate transfer or follow its policy when record reviews show that Patient #1 was not routed through the transfer center upon transfer.

Facility A's 'Medical Screening Examinations and Patient Transfers Policy', last reviewed by Facility A and became effective on 11/10/2022, states on page 20:
"5.0 Definitions:
5.1 Appropriate Transfer - An appropriate transfer to another hospital is a transfer:
5.1.1 in which the transferring hospital provides the medical treatment within its
Capacity which minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child;
5.1 .2 in which the receiving hospital has available space and qualified personnel for the treatment of the individual, and has agreed to accept the transfer of the individual and to provide appropriate medical treatment.
5.1.3 in which the transferring hospital sends to the receiving hospital all
medical records (or copies thereof) related to the emergency condition for
which the individual has presented, available at the time of the transfer
(as further defined by this policy); and
5.1.4 in which the transfer is effected through qualified personnel and
transportation equipment as required, including the use of necessary and
medically appropriate life support measures during the transfer."

The Director of Quality, Patient Safety, and Risk Management, Staff #21, was asked how Facility A handles facility-to-facility transfers for patients they do not have the capacity to treat, such as behavioral or psychiatric patients. Staff #21, replied that normally when it is an uncomplicated case (meaning not like that of Patient #1) the MOT would be filled out, the Behavioral Health Transfer Center would be contacted by the LMSW or ED physician and the patient would be transferred by the means necessary for that patient.

On the morning of July 11, 2023, the Chief Quality Medical Officer (Staff #2) was asked why there was no MOT sent with Patient #1 and the SPD officer (Staff #30) prior to leaving Facility A to go to Facility B. Staff #2 replied that he had concerns that Staff #30 may have a need to transport Patient #1 to a facility other than Facility B (as had been discussed) and that the MOT would then be construed as a HIPPA violation at any other facility