HospitalInspections.org

Based on document review and staff interview, in 1 (one) of 20 medical records (MR) reviewed, the facility did not report to the state agency in seventy-two hours of receiving a patient who had not been appropriately transferred. (Patient #1).

Findings include:

Review of the medical record for Patient #1, identified: a twenty-two year old patient, who on January 14, 2016 at 12:15 AM, "arrived escorted in cuffs to the emergency department (ED) by 2 police officers. Upon arrival at this facility the patient's memory and cognition were impaired, he was impulsive and he had inappropriate judgment. Patient was rambling non-stop, not making sense and "had rapid delusional and tangential speech pattern." The physician's documentation at 12:34 AM stated; the patient was initially taken to another hospital for a mental health evaluation and while there the patient became very agitated and the police was called. This doctor also documented that he had received a call from a doctor at the other facility that night, who wanted to transfer the patient to this facility because the patient had threatened to kill staff at their facility and their Chief Operating Officer had instructed them not to treat or admit the patient at that facility. The physician had conducted a medical screening examination but no blood work or psychiatric exam had been done. The doctor (the MD at the transferring facility) also stated that he was going to discharge the patient to the police.

During interview with Staff #1, (Vice President, Patient Care) on February 11, 2016 at 2:00 PM, she indicated that this case was not reported as an inappropriate transfer to the State Agency. The case was reported on February 10 and 11, 2016, which is almost a month after the administrative staff became aware that the incident had occurred.

The facility's policy and procedure titled "Emergency Medical Treatment and Labor Act ("EMTALA") Policy including Triage and Medical Screening," last revised on 4/10/2015, stated the following: "If hospital staff suspects that an improper transfer of an unstable patient has occurred, Risk Management should be notified immediately. Depending on the circumstances, the hospital may need to report to CMS and the State agency within 72 hours of this occurrence."

The facility did not follow this policy to report an inappropriate transfer to the State Agency or CMS within 72 hours of the occurrence.