HospitalInspections.org

Based on review of records and interviews, the hospital failed to comply with 489.24 in that:

1) 1 of 1 patient (Patient #1) who presented to the Emergency Department for emergency medical treatment was improperly transferred to another facility for specialized psychiatric treatment which the transferring facility did not provide.

2) The hospital failed to enforce the Patient Transfer policy to ensure compliance with the requirements of 489.24.

Cross Reference: A2409

Based on interview and record review, the hospital failed to provide an appropriate transfer to 1 of 1 patient (Patient #1) treated in the Emergency Department (ED) on 02/15/11 for overdose and attempted suicide. The patient was inappropriately transferred to Hospital A by PD. The hospital staff did not notify, request or obtain permission from the receiving hospital for the patient transfer, send copies of the medical record and required paperwork related to the emergency medical condition, or transport the patient with appropriate equipment and personnel.

Findings Included:

Patient #1, presented to Methodist Charlton MC Emergency Department on 02/15/11 at 5:28 A.M. with complaints of overdose (OD) and attempted suicide. The medical record revealed he was treated for the OD and received a psychiatric evaluation. The psychiatric evaluation, not timed revealed, "Recommend evaluation by a psychiatrist for possible inpatient care."

The Physician (Personnel #6) documented in the "Physician Notes" timed at 9:00 A.M. revealed, "[Hospital C] here evaluating and patient became agitated and states he wants to go home and "finish it off". We will do an APOWW [Peace Officer Application for Emergency Detention without warrant] to [Hospital A]."

At 9:05 A.M., the physician notes revealed, "Patient calm and resting. Aware of pending transfer to [Hospital A]."

The RN (Registered Nurse, Personnel #22) documented at 9:13 A.M. in the "Nursing Notes," "Medically cleared, patient left with [PD] to be transferred to [Hospital A]."

There was no discharge assessment, neurological assessment, discharge vital signs, self harm screening assessment, disposition, mode of discharge, discharge instructions or the required transfer paperwork documented or included in the nursing notes.

The "Physician Orders" did not show an order to discharge or transfer patient to Hospital A.

The Medical Record did not contain a copy of the Application for Court-Ordered Mental Health Services, Physician's Certificate for Medical Examination for Mental Illness, the Addendum, Memorandum of Transfer or a Single Portal Authority (SPA) letter to the Mental Illness Court to show acceptance of the patient to a facility.

There was no patient consent form in the medical record or documentation by the nurse or physician in the attempt to obtain consent from the patient for transfer to Hospital A.

Patient #1's medical record dated 02/15/11, timed at 9:50 A.M. from Hospital A ED revealed, "ED Admission Notes - [Patient #1] arrived under APOWW by the [PD] for Overdose, Acute Alcoholic Intoxication and Mood Disorder."

The medical record did not contain documentation showing a nurse or physician report, a copy of the Application for Court-Ordered Mental Health Services, Physician's Certificate for Medical Examination for Mental Illness, the Addendum, Memorandum of Transfer or a Single Portal Authority (SPA) letter to the Mental Illness Court to show acceptance of the patient to a facility from Methodist Charlton MC.

In an interview at 10:00 A.M. on 03/03/11, the physician (Personnel #6) was interviewed. She was asked to review the medical record of Patient #1. She was then asked if she was the ED physician that provided care to Patient #1. She stated, "Yes. The patient was brought in because he had threatened suicide and OD'd. He had been started on charcoal, and had vomited and was tachycardic (fast heart rate). The initial plan was to treat and send him home. I told [Hospital C] he was medically cleared. After he was evaluated by [Hospital C], he said we would APOWW him to [Hospital A] because [Patient #1] told him he was going to go home and finish it off." She was asked if the hospital policies and procedures were followed for appropriate patient transfer. She stated, "No."

In an interview at 9:15 AM on 03/07/11, the RN (Personnel #22) was interviewed. She was asked to review the medical record of Patient #1. She was then asked if she was assigned to take care of Patient #1. She stated, "Yes. He was there for intoxication and overdose. [PD] and his girlfriend was in the room. His treatment was finished except for the second liter of saline going in. [Hospital C] came in and saw the patient. When [Hospital C] was finished, he tried to give me report and I was on the phone. I asked him to give me a minute because I was giving report on another patient. He told me to discharge the patient. He was going to [Hospital A]. Shortly after [Hospital C] left, the [PD] had the patient up and dressed. I had them take off the handcuffs so I could take out the IV and have him sign the discharge paperwork. They put the cuffs back on and took him to [Hospital A]."
She was asked if the medical record contained a discharge or transfer order from the physician. She stated, "No." She was asked if she had followed hospital policies and procedures for an appropriate patient transfer. She stated, "No."

The Administrative Policy, "Psychiatric Care/Referral": dated 08/30/10 required, "Although ...does not have a Psychiatric Unit...will provide to patients...referral to appropriate facilities for serious psychiatric conditions...For any patient involuntarily transferred to a mental health facility the physician shall complete and the forms shall be notarized, as indicated: A. Physician Assessment Prior to Transfer, B. Memorandum of Transfer, C. Application for Court Ordered Mental Health Services - Temporary, D. Physician's Certification of Medical Examination for Mental Illness, E. Physician's Certification of Medical Examination for Mental Illness - Addendum, F. Physician's Order Form and Discharge Instructions...To arrange for transport the Social Worker or Charge Nurse will arrange an ambulance or ...as appropriate, once the patient is medically stable. The ...will accompany the transport if the ambulance staff would be at risk or for every APOWW...Involuntary Patients in the ED: Once the medical staff has determined the necessity of a psychiatric evaluation for the patient and the patient is deemed medically stable, the physician should refer to the Medical Management/Social Worker to initiate the psychiatric evaluation on-site by the mobile assessment team...once the team completes the assessment and determines the most appropriate care for the patient, ...staff will facilitate recommended plan of care for patient with assistance from ...as needed...If recommendation is OPC (Order of Protective Custody) then follow involuntary patient requirements...A copy of the Application for Court-Ordered Mental Health Services, Physician's Certificate for Medical Examination for Mental Illness, the Addendum, and History Sheet should be kept in the patient's medical record. The original and a second copy should be sent to the Mental Illness Court...the patient should be detained at the hospital and not allowed to leave...Call the Single Portal Authority (SPA)...will send a letter to the Mental Illness Court to show acceptance of the patient to a facility...Arrange transportation when all paperwork (the OPC document signed by the presiding Judge, the SPA letter assigning a bed, Memorandum of Transfer is completed. Appropriate transportation is via ambulance only...Ensure that the physician-to-physician and nurse-to-nurse report has occurred...Place a photocopy of all documents, including a copy of the patients chart, in an envelope and send with the patient to their assigned facility...mail original copy of all documents to Mental Health Court..."

The Administrative Policy, "Patient Transfers": dated 04/30/09 required, "The Board of Directors...adopted this policy to comply with state and federal laws regulating transfers of patients from ...to other hospitals...must be complied with whenever a patient is transferred...the charge nurse, Nursing Supervisor or Administrator on Call will have the authority to represent each ...hospital and the physician with regard to the transfer from or receipt of patients...The transfer of a patient may not be predicated upon arbitrary, capricious or unreasonable discrimination...the transfer of patients who require emergency services...as determined by a physician...the physician who authorized the transfer shall...assure the proper transfer procedures are used...and complete the form entitled Physician Assessment Prior to Transfer and sign the Memorandum of Transfer...shall determine and order the utilization of appropriate personnel and equipment for the transfer...will secure a receiving physician and a receiving hospital that are appropriate to the medical needs of the patient and that will accept responsibility for the patient's medical treatment and hospital care...A Memorandum of Transfer shall be completed on every transfer...Charge nurses, physician, social worker, nursing supervisor or administrator on call will contact accepting facility to confirm administrative approval, obtain room number and/or specific area that is receiving the patient and a telephone number to call report...will ensure that...qualified personnel are available and on duty to assist with arrangements for patient transfers and to provide accurate information...and written protocols or standing delegation orders are in place to guide hospital personnel when a patient requires transfer to another hospital...shall implement procedures for the hospitals medical staff to review appropriate records of patients transferred from the hospital to determine that the appropriate standard of care has been met...Medical Records: During a transfer...the hospital shall provide a copy of those portions of the patient's medical record...are relevant to the transfer and to the continuing care of the patient are forwarded to the receiving physician and hospital with the patient...The medical records shall contain at a minimum: A brief description of the patients medical history and physical examination, a working diagnosis...physical assessment of patients condition at the time of transfer...reason for transfer...results of all diagnostic tests...medication reconciliation...Memorandum of Transfer: ...will complete a MOT for every patient who is transferred...will be signed by transferring physician and must also be signed by a Nursing Supervisor, Charge Nurse, Social Worker, or administrative designee in compliance with hospital policy...administrative approval and approval of the accepting physician at the receiving facility must be completed prior to ... representative signing the form...Original MOT will accompany the patient being transferred...a copy of the MOT will be retained and filed separately from the medical record...compliance with this policy is mandatory..."

In an interview at 11:00 A.M. on 03/01/11,the CNO (Personnel #1) was interviewed. She was asked to review the medical record of Patient #1. She was then asked if the staff followed the hospital policies and procedures for patient transfers. She stated, "No."