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Based on document review and staff interview, it was determined the hospital failed to:

a. provide an appropriate medical screening examination for all mental health patients who came to the hospital's emergency department. See tag A-2406; and

b. failed to provide for an appropriate transfer of mental health patients with unstable psychiatric illnesses to a hospital with the specialized capability to stabilize their condition. See tag A-2409.

This had the potential to affect all mental health patients who sought treatment in the hospital's emergency department.

Based on document review and staff interview, it was determined the hospital failed to provide an appropriate medical screening exam for 24 of 62 patients included in a patient sample that was reviewed for medical screening examination.

Findings:

1. On 05/18/2016 at 3:38 p.m., the emergency department record for patient #14 documented the patient arrived to the emergency department escorted by law enforcement. The record documented, "Chief Complaint - Medical Clearance... pt has bed at [hospital name deleted] psych unit but needs medically cleared..." The record documented one set of vital signs were obtained at 3:44 p.m.

At 4:07 p.m., emergency department physician #1 documented the patient was "well known to this facility for intentional overdose and suicidal ideations. Today the patient once again expressed some suicidal ideations... The patient denies any intentional overdose at this time. He does admit he drank some alcohol earlier today. He otherwise is not having any symptoms. No chest pain. No shortness of breath."

There was no documentation of an EKG, drug screening, toxicology levels or laboratory studies ordered for the patient. There was no documentation of a psychiatric evaluation by the physician or by the hospital's contracted telemedicine service that provided psychiatric evaluations by a licensed mental health professional.

The record documented the patient was currently taking the following medications: naproxen, hydrocodone-acetaminophen, alprazolam, neurotin, trihexyphenidyl, chlorpromazine and methocarbamol.

The record also documented the patient was previously seen in the hospital's emergency department on the following dates for these complaints:

05/17/16 - arm pain
05/11/16 - shoulder and back pain
05/07/16 - intentional overdose
03/12/16 - alcohol problem
01/16/16 - drug overdose
10/21/15 - aggressive behavior

An un-timed entry by the physician documented the following, "I have reviewed the nursing notes and vitals. I have interpreted the following results: oxygen saturation. The patient was seen and examined. The patient is ambulatory at the scene. He ambulates without any difficulty. He does appear slightly intoxicated. He follows all commands. He does not have any signs of trauma. I do not think he needs any lab work, EKG or radiologic studies. I think the patient is safe to go to [facility name deleted] at this time. I have asked the officer to bring on back immediately if any other symptoms worsen or have any concerns..."

At 4:11 p.m., the ED physician documented on a doctor's order form, "Patient is medically cleared."

The record documented the nurse signed off the patient's case at 4:20 p.m. and the physician signed off the case at 4:22 p.m.

The record documented a second set of vital signs at 4:41 p.m. The record had no other documentation after this time. It could not be determined when the patient left the emergency department, his condition at the time of transfer or his destination.

On 06/08/2016, emergency department staff member #2 was asked to review the patient's medical record. She was asked if this was a typical medical screening examination for a mental health patient. She stated, "This doesn't make sense to me. Let me see if there is any information missing. There is no screening that we usually do for this kind of patient - labs, EKG - for medical clearance. There is no psychiatric evaluation. And I can't tell for sure where he was sent..."

At the conclusion of the survey, no other medical record information for the date of service 05/18/2016 had been found for this patient.

2. During a review of the patient sample, it was found that some mental health patients who presented to the emergency department received a psychiatric evaluation by a licensed mental health professional. These evaluations were done via telemedicine with another hospital. The staff were asked why some patients were evaluated in this manner and some were not. The emergency department staff stated that it was the usual practice that primarily, only mental health patients with insurance were evaluated by telemedicine. Twenty-four patients (#1, #4, #5, #7, #14, #16, #17, #22, #31, #33, #35, #36, #37, #39, #40, #46, #47, #50, #52, #53, #54, #55, #56 and #60) had no documentation of a payer source and also had no documentation of a psychiatric evaluation by a licensed mental health professional. According to the emergency department staff, these patients were considered unstable and that was why they needed to be transferred.

Based on document review and staff interview, it was determined the hospital failed to:

a. ensure unstable mental health patients were transferred to a hospital with the capacity and specialized capabilities to care for unstable mental health patients. This was found for 30 of 60 mental health patients included in the sample;

b. obtain patient consent or document patient refusal to transfer and failed to provide physician certification that the medical benefits outweighed the risks of transfer. This was found for 34 of 60 mental health patients included in the sample;

c. transfer mental health patients to a hospital and a physician that have agreed to accept the transfer. This was found for 42 of 60 mental health patients included in the sample; and

d. the hospital failed to send medical records related to the patient's emergency condition to the receiving hospital for 62 of 62 patients in the sample.

Findings:

During the course of the complaint survey, 62 patient records were selected for review. All 62 patients were documented on the emergency department log as "transfers" from the hospital's emergency department. Two patients in the sample were physical illness-related transfers to other hospitals for specialized care. Sixty patients in the sample were transferred elsewhere for mental health reasons.

1. All 60 mental health patients in the sample were identified by the hospital to have emergency psychiatric conditions that required stabilization and inpatient psychiatric care.
Six patient records (#1, #16, #17, #18, #20 and #42) had no documentation of the patient's transfer destination. Five patient records (#4, #11, #14, #25 and #54) had conflicting information about the receiving facility. One patient record (#27) documented only the name of the town where the patient was transferred.

Twenty-four of these patients (#4 through #8, #14, #15, #19, #22, #31, #33, #35 through #37, #40, #46, #47, #50 through #53, #55, #56, #60 and #61) were not provided a transfer to a hospital with the specialized capabilities to stabilize psychiatric emergencies. Instead, the patients were transferred to non-hospital mental health facilities such as community crisis centers and other types of facilities with unknown patient care capabilities.

The hospital emergency department staff and the director of emergency services were asked what they knew about these facilities and their capabilities. They stated they had no information on the types of services they provided or the level of care. The staff were uncertain as to the types of staff (physicians, therapists, RN's, LPN's, technicians, aides, etc.) who provided care at these locations. The hospital emergency department staff were also uncertain as to the exact locations where the patients were transferred because those mental health entities were known to have different services at various locations around the state.

The emergency department staff were asked why patients were transferred to non-hospital facilities. They stated, "They had beds available when we asked for them and those places are on our list of mental health facilities for referral."

The staff were asked why these patients were not transferred to hospitals with inpatient psychiatric care capabilities. They stated those hospitals sometimes did not have a bed available and sometimes the hospitals would refuse to make a decision about accepting a patient for transfer until they received the patient demographic information, including payer source information. They stated some hospitals declined transfers after they had received the patient's payer source information.

The clinical record for patient #24 documented the receiving hospital required verification of insurance benefits before the patient would be accepted for transfer.

They also stated some psychiatric hospitals and hospital psychiatric units would not accept mental health patient transfers unless the patient had been evaluated by a licensed mental health professional. The emergency department staff stated this was because those hospitals would not accept the emergency department physician's assessment and diagnosis of the patient.

The emergency department staff stated the hospital could provide a psychiatric evaluation by a licensed mental health professional via telemedicine with another hospital, but not all patients received this evaluation. When asked why not, the staff stated that it was the hospital's practice to provide the telemedicine psychiatric evaluations primarily to "patients with insurance."

Twenty-four patient records (#1, #4, #5, #7, #14, #16, #17, #22, #31, #33, #35, #36, #37, #39, #40, #46, #47, #50, #52, #53, #54, #55, #56 and #60) documented these patients had no payer source and were not provided a telemedicine psychiatric evaluation. These patients were also transferred to non-hospital level of care.

The emergency department staff were asked if they required a potential receiving hospital to declare a reason for the refusal to accept a transfer. They stated they did not. The staff were asked if they documented the unsuccessful attempts to transfer to other hospitals. They stated they did not.

2. Thirty-four (#1 through #7, #10, #13 through #21, #25, #30, #34, #35, #37 through #42, #46 through #49, #51, #54, and #62) of the sixty mental health patients transferred to other facilities had no documentation of physician certification of transfer. An additional eight patients in the sample had physician certification of transfer forms that were incomplete and missing information to include the name of the receiving facility, the accepting physician, the patient's condition at transfer and the mode of transportation. Some physician certification of transfer forms did not document the physician's evaluation of the risks and benefits of transfer. Some forms did not document the name of the person accepting the transfer.

When a physician certification of transfer form was found in the record, the patient consent or refusal to transfer was not documented or the information provided on the form was contradictory.

For example, the certification of transfer for patient #55 documented the patient "requested transfer due to preference" but the patient did not sign the transfer consent portion of the document. Instead, the staff wrote in the patient signature line "EOD." This referred to a term used by the hospital staff that meant 'emergency order of detention,' when in fact the patient was in police protective custody. By documenting 'EOD' the staff implied the patient was an involuntary mental health patient and the transfer to another facility was not an option for the patient. As was the case with patient #55, many mental health patients documented as 'EOD' status had no official emergency detention documentation, but were actually in police protective custody.

The mental health patient records that had physician certification of transfer did not always document patient consent for transfer or patient refusal for transfer. In addition, the form required patients to sign when they requested to be transported to another hospital by a means other than by ambulance. The hospital did not have mental health patients sign this portion of the form even though all mental health patients who were transferred to another facility (including hospitals) were transported in a law enforcement vehicle and not by ambulance service. The emergency department staff stated mental health patients were transported this way because they were considered "unstable and a risk to themselves or others."

3. Forty-two (#1, #3 through #8, #10, #14 through #22, #25, #27, #28, #30, #31, #33, #35, #36 through #38, #40 through #42, #44, #46 through #48, #51, #52, #54 through #56, #58, #60 and #61) of the sixty mental health patient records reviewed had no documentation anywhere in the record of an accepting facility (hospital or non-hospital) and no documentation of an accepting physician. These records also did not have documentation of physician to physician communication regarding the patient's condition or nurse to nurse communication regarding the transfer of patient care to the receiving facility.

4. Although hospital policy and medical staff rules and regulations required it, none of the 62 patient records in the sample had documentation of the specific medical record information sent to the receiving facility, how this information was transmitted, and who received it. The emergency department staff stated it was not their practice to document the details but they "always sent the medical record information when patients were transferred."

On 06/09/2016, various staff at the receiving hospital stated no medical record information was given to them regarding the patient #14's examination and treatment provided at the sending hospital, St. Anthony Shawnee Hospital. The patient arrived at the receiving hospital on 05/18/2016 without prior notice and without medical record information, according the staff.