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Based on medical record review, policy review, and staff interview the facility transferred a patient to another medical facility without following their own policy, having a signed physician certification of the medical benefits from the transfer, and receiving approval from the recipient facility for the transfer of the patient. 18 of 20 records were deficient for including all the necessary documentation required on a patient transfer form.

Findings were:

Review of medical record, on 10/6/15 in the conference room, for patient #1 reveals the following:
* Inquiry Call Form reveals: Patient was referred to their facility for suicidal ideations and was brought to the facility accompanied by a police officer with an emergency detention order.
* Admission Assessment Form reveals: accompanied by self. Referral source: police. Clinical formulation: Patient is a 20 year old female who presents to the facility on an emergency detention. Patient requires 1:1 staffing and was transferred out to facility #4 for more appropriate placement. Case staffed with Director of Admissions, House Supervisor, and on call physician. At this time the facility did not have adequate staffing.
This medical screening evaluation form is signed by staff #6 who is a Licensed Social Worker and a Licensed Professional Counselor Intern.
* Transfer Form: Patient Certification for transfer and Accepting Facility, Administrator, and Physician area is blank.

Medical record review for 19 additional patients that were transferred out from the facility between 5/24/15 and 10/6/15 revealed 17 of the 19 patients were transferred to hospitals:
* 1 transfer, patient #7 (10/6/15) was a parent visiting in the facility who experienced chest pain; physician certification was filled out but physician signature was a printed name and not signed by the physician; the accepting facility information stated the nurse said they did not need to ask for transfer in an emergency situation and send the patient to the ER by ambulance;
* 1 transfer, patient # 19 (8/25/15) had physician certification filled out with a printed physician name and not countersigned by physician, and no accepting facility information for administrator or physician acceptance of transfer;
* 13 patients, patient #2 (5/24/15), patient #3 (6/22/15), patient #4 (8/17/15), patient #5 (8/16/15), patient #9 (8/3/15), patient #10 (8/4/15), patient #11 (8/11/15), patient #12 (9/25/15), patient #14 (9/11/15), patient #15 (8/27/15), patient #16 (9/9/15), patient #18 (9/3/15), and patient #20 (8/3/15) had no physician certification signed for transfer and had no accepting facility information for administrator or physician acceptance of transfer;
* 2 patients, patient #6 (8/22/15) and patient #8 (8/2/15) were sent out for medical clearance and did not have physician certification signed and had accepting hospital information for administrator as "SW on Duty" and physician acceptance as "MD @ ED" at accepting facility.

Facility document, approved 6/10/13 by the Governing Board, titled "Governing Board Bylaws" states in part "The following mental health professionals are deemed to be credentialed to perform medical screening examinations to determine whether an individual has an emergency medical condition and, therefore are Qualified Mental Health Professionals (QMHP): Licensed Social Workers; Registered Nurses; Licensed Professional Counselors."

Facility Policy, effective 6/10/13, titled "Medical Screening" states in part "The initial screening is conducted by Registered Nurse (RN) or Qualified Mental Health Provider (QMHP). Medically cleared-an individual is considered medically cleared if the medical screening does not reveal an acute medical condition. An RN shall review and initial all medical screens conducted by a non-RN QMHP."

Facility policy, effective 6/10/13, titled "Exclusionary Criteria" states in part "Exclusionary Criteria: Patients unable to feed or toilet self. Patients in need of total assist, or in need of a lift. If a patient is found to have one or more exclusionary criterion listed under #1, he or she will be referred to a more appropriate provider/facility."

Facility policy, effective 6/10/13, titled "Patient Transfer" states in part "Transfer of patients who do not have emergency medical conditions: All reasonable steps are taken to secure the informed refusal of a patient refusing a transfer: a factual explanation of the medical benefits reasonable expected from the provision of appropriate treatment at a receiving hospital. The informed refusal of a patient to examination, evaluation, or transfer shall be documented and signed by the patient, dated and witnessed by the attending physician or facility employee and placed in the patient's medical record. Physician duties and standard of care: Prior to transfer, the transferring physician shall secure a receiving physician and a receiving facility that are appropriate to the medical needs of the patient and that will accept responsibility for the patient's medical treatment and care."

In an interview with the Director of Admissions on 10/6/15 she stated patient #1 came by law enforcement with an emergency detention order: (Texas Health and Safety Code 573.001. APPREHENSION BY PEACE OFFICER WITHOUT WARRANT. (a) A peace officer, without a warrant, may take a patient into custody if the officer: (1) has reason to believe and does believe that: (A) the person is mentally ill; and (B) because of that mental illness there is a substantial risk of serious harm to the person and others unless the person is immediately restrained; and (2) believes that there is not sufficient time to obtain a warrant before taking the person into custody.) She stated facility #1 called and inquired about a bed and the facility said they would do an assessment. She stated they did not have a copy of the emergency detention order in the chart of patient #1. She said the staff #5 spoke to the nurse in the emergency room. She said no one spoke to a house supervisor or physician at the receiving facility for acceptance of the patient. She said staff #5 called facility #4 and they refused her transfer because they do not have psychiatric services.

In an interview, on 10/6/15, with the Qualified Mental Health Professional performing the medical screening of patient #1 she stated patient #1 was brought in by the police on an emergency detention order. She said she gave all the transfer forms and emergency detention order to EMS and did not have a copy in their medical record for patient #1.

In an interview with the Director of Admissions on 10/7/15 she stated their facility does not speak with a supervisor or an emergency room physician to accept their patients when they are transferring them to the facility for medical screening or a higher level of care and they only call and talk to the emergency room nurse. She stated she was not aware the facility policy required them to talk to an accepting physician.

In an interview with the Quality Manager of the recipient facility she stated their facility did not accept the transfer of patient #1 because they did not provide psychiatric services and the patient did not have an emergency medical condition. She further stated the only people in their facility to approve a transfer from another hospital is the emergency room physician or the house supervisor and facility #2 did not contact either prior to the transfer of patient #1 to their emergency department. She stated patient #1 remained in their emergency department for about 8 hours until they could arrange a transfer back to her group home.

Based on medical record review and staff interview the facility failed to keep originals of all documents in a patient medical record that was transferred to their hospital on an emergency detention order. 1of 20 medical records reviewed did not contain original documents of all medical records that were referenced in the patient medical record.

Findings were:

Review of medical record for patient #1 on 10/6/15 revealed there was no documentation of an emergency detention order in the medical record. This document was referenced by the Director of Admissions and Qualified Mental Health Professional in an interview on 10/6/15 and on the "Inquiry Call Form" present in the patient's medical record. Upon their own review of the medical record neither could produce the emergency detention order for the patient.

The Qualified Mental Health Professional on 10/6/15 also referenced attempts by the facility to transfer the patient to a psychiatric emergency room and stated a transfer form was filled out for the patient to be transported by ambulance to that facility and the patient refused to go to the psychiatric emergency room. Upon her own review of the medical record she could produce no documentation of efforts to transfer the patient to another facility with psychiatric care capabilities.

In an interview with the Director of Admissions and the Qualified Mental Health Professional (QMHP) on 10/6/15 both stated there was no documentation they could find in the patient medical record of the emergency detention order that accompanied the patient when she presented to the facility for evaluation. The QMHP stated she thought the original emergency detention order for the patient went with the patient when transferred out of their hospital. The QMHP also stated there was no documentation in the medical record for patient #1 to indicate they had tried to transfer the patient to a hospital with psychiatric capabilities and/or the patient refused to be transferred to that facility.

Based on medical record review, policy review, and staff interview the facility transferred a patient to another medical facility without providing the patient with a medical screening as well as a psychiatric screening after the patient presented to the facility with an emergency detention order for suicidal ideations.

Findings were:

Review of medical record, on 10/6/15 in the conference room, for patient #1 reveals the following:
* Inquiry Call Form reveals: Patient was referred to their facility for suicidal ideations and was brought to the facility accompanied by a police officer with an emergency detention order.
* Admission Assessment Form reveals: accompanied by self. Referral source: police. Clinical formulation: Patient is a 20 year old female who presents to the facility on an emergency detention. Patient requires 1:1 staffing and was transferred out to facility #4 for more appropriate placement. Case staffed with Director of Admissions, House Supervisor, and on call physician. At this time the facility did not have adequate staffing.
* This medical screening evaluation form is signed by staff #6 who is a Licensed Social Worker and a Licensed Professional Counselor Intern.
* No evidence of documentation of an initial psychiatric evaluation of the patient was in the medical record.

Facility document, approved 6/10/13 by the Governing Board, titled "Governing Board Bylaws" states in part "The following mental health professionals are deemed to be credentialed to perform medical screening examinations to determine whether an individual has an emergency medical condition and, therefore are Qualified Mental Health Professionals (QMHP): Licensed Social Workers; Registered Nurses; Licensed Professional Counselors."

Facility Policy, effective 6/10/13, titled "Medical Screening" states in part "The initial screening is conducted by Registered Nurse (RN) or Qualified Mental Health Provider (QMHP). Medically cleared-an individual is considered medically cleared if the medical screening does not reveal an acute medical condition. An RN shall review and initial all medical screens conducted by a non-RN QMHP."

In an interview with the Director of Admissions on 10/6/15 she stated patient #1 came by law enforcement with an emergency detention order: (Texas Health and Safety Code 573.001. APPREHENSION BY PEACE OFFICER WITHOUT WARRANT. (a) A peace officer, without a warrant, may take a patient into custody if the officer: (1) has reason to believe and does believe that: (A) the person is mentally ill; and (B) because of that mental illness there is a substantial risk of serious harm to the person and others unless the person is immediately restrained; and (2) believes that there is not sufficient time to obtain a warrant before taking the person into custody.) She stated facility #1 called and inquired about a bed and the facility said they would do an assessment. She stated they did not have a copy of the emergency detention order in the chart of patient #1.

In an interview, on 10/6/15, with the Qualified Mental Health Professional performing the medical screening of patient #1, she stated patient #1 was blind and they did not perform an initial psychiatric screening for the patient prior to trying to transfer her because they stated they would not admit her because she was blind.

In an interview with the Director of Admissions and the Qualified Mental Health Professional (QMHP) on 10/6/15 both stated there was no documentation they could find in the patient medical record of the emergency detention order that accompanied the patient when she presented to the facility for evaluation. The QMHP stated she thought the original emergency detention order for the patient went with the patient when transferred out of their hospital. The QMHP also stated there was no documentation in the medical record for patient #1 to indicate they had tried to transfer the patient to a hospital with psychiatric capabilities and/or the patient refused to be transferred to that facility.

Based on medical record review, policy review, and staff interview the facility transferred a patient to another medical facility without following their own policy, having a signed physician certification of the medical benefits from the transfer, and receiving approval from the recipient facility for the transfer of the patient. 18 of 20 records were deficient for including all the necessary documentation required on a patient transfer form.

Findings were:

Review of medical record, on 10/6/15 in the conference room, for patient #1 reveals the following:
* Inquiry Call Form reveals: Patient was referred to their facility for suicidal ideations and was brought to the facility accompanied by a police officer with an emergency detention order.
* Admission Assessment Form reveals: accompanied by self. Referral source: police. Clinical formulation: Patient is a 20 year old female who presents to the facility on an emergency detention. Patient requires 1:1 staffing and was transferred out to facility #4 for more appropriate placement. Case staffed with Director of Admissions, House Supervisor, and on call physician. At this time the facility did not have adequate staffing.
This medical screening evaluation form is signed by staff #6 who is a Licensed Social Worker and a Licensed Professional Counselor Intern.
* Transfer Form: Patient Certification for transfer and Accepting Facility, Administrator, and Physician area is blank.

Medical record review for 19 additional patients that were transferred out from the facility between 5/24/15 and 10/6/15 revealed 17 of the 19 patients were transferred to hospitals:
* 1 transfer, patient #7 (10/6/15) was a parent visiting in the facility who experienced chest pain; physician certification was filled out but physician signature was a printed name and not signed by the physician; the accepting facility information stated the nurse said they did not need to ask for transfer in an emergency situation and send the patient to the ER by ambulance;
* 1 transfer, patient # 19 (8/25/15) had physician certification filled out with a printed physician name and not countersigned by physician, and no accepting facility information for administrator or physician acceptance of transfer;
* 13 patients, patient #2 (5/24/15), patient #3 (6/22/15), patient #4 (8/17/15), patient #5 (8/16/15), patient #9 (8/3/15), patient #10 (8/4/15), patient #11 (8/11/15), patient #12 (9/25/15), patient #14 (9/11/15), patient #15 (8/27/15), patient #16 (9/9/15), patient #18 (9/3/15), and patient #20 (8/3/15) had no physician certification signed for transfer and had no accepting facility information for administrator or physician acceptance of transfer;
* 2 patients, patient #6 (8/22/15) and patient #8 (8/2/15) were sent out for medical clearance and did not have physician certification signed and had accepting hospital information for administrator as "SW on Duty" and physician acceptance as "MD @ ED" at accepting facility.

Facility document, approved 6/10/13 by the Governing Board, titled "Governing Board Bylaws" states in part "The following mental health professionals are deemed to be credentialed to perform medical screening examinations to determine whether an individual has an emergency medical condition and, therefore are Qualified Mental Health Professionals (QMHP): Licensed Social Workers; Registered Nurses; Licensed Professional Counselors."

Facility Policy, effective 6/10/13, titled "Medical Screening" states in part "The initial screening is conducted by Registered Nurse (RN) or Qualified Mental Health Provider (QMHP). Medically cleared-an individual is considered medically cleared if the medical screening does not reveal an acute medical condition. An RN shall review and initial all medical screens conducted by a non-RN QMHP."

Facility policy, effective 6/10/13, titled "Exclusionary Criteria" states in part "Exclusionary Criteria: Patients unable to feed or toilet self. Patients in need of total assist, or in need of a lift. If a patient is found to have one or more exclusionary criterion listed under #1, he or she will be referred to a more appropriate provider/facility."

Facility policy, effective 6/10/13, titled "Patient Transfer" states in part "Transfer of patients who do not have emergency medical conditions: All reasonable steps are taken to secure the informed refusal of a patient refusing a transfer: a factual explanation of the medical benefits reasonable expected from the provision of appropriate treatment at a receiving hospital. The informed refusal of a patient to examination, evaluation, or transfer shall be documented and signed by the patient, dated and witnessed by the attending physician or facility employee and placed in the patient's medical record. Physician duties and standard of care: Prior to transfer, the transferring physician shall secure a receiving physician and a receiving facility that are appropriate to the medical needs of the patient and that will accept responsibility for the patient's medical treatment and care."

In an interview with the Director of Admissions on 10/6/15 she stated patient #1 came by law enforcement with an emergency detention order: (Texas Health and Safety Code 573.001. APPREHENSION BY PEACE OFFICER WITHOUT WARRANT. (a) A peace officer, without a warrant, may take a patient into custody if the officer: (1) has reason to believe and does believe that: (A) the person is mentally ill; and (B) because of that mental illness there is a substantial risk of serious harm to the person and others unless the person is immediately restrained; and (2) believes that there is not sufficient time to obtain a warrant before taking the person into custody.) She stated facility #1 called and inquired about a bed and the facility said they would do an assessment. She stated they did not have a copy of the emergency detention order in the chart of patient #1. She said the staff #5 spoke to the nurse in the emergency room. She said no one spoke to a house supervisor or physician at the receiving facility for acceptance of the patient. She said staff #5 called facility #4 and they refused her transfer because they do not have psychiatric services.

In an interview, on 10/6/15, with the Qualified Mental Health Professional performing the medical screening of patient #1 she stated patient #1 was brought in by the police on an emergency detention order. She said she gave all the transfer forms and emergency detention order to EMS and did not have a copy in their medical record for patient #1.

In an interview with the Director of Admissions on 10/7/15 she stated their facility does not speak with a supervisor or an emergency room physician to accept their patients when they are transferring them to the facility for medical screening or a higher level of care and they only call and talk to the emergency room nurse. She stated she was not aware the facility policy required them to talk to an accepting physician.

In an interview with the Quality Manager of the recipient facility she stated their facility did not accept the transfer of patient #1 because they did not provide psychiatric services and the patient did not have an emergency medical condition. She further stated the only people in their facility to approve a transfer from another hospital is the emergency room physician or the house supervisor and facility #2 did not contact either prior to the transfer of patient #1 to their emergency department. She stated patient #1 remained in their emergency department for about 8 hours until they could arrange a transfer back to her group home.