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Based on an observational tour, review of medical records, hospital policies and procedure, physician on-call schedules, medical records (MR), Geriatric and Adult psychiatric unit bed census reports, Ambulance Run Report, and interviews, it was determined the hospital failed to minimize the risks to the individual's health by failing to provide medical treatment within its capacity, as this resulted in an inappropriate transfer of Patient Identifier (PI) # 1.

This affected one of three psychiatric patients reviewed who were transferred from the facility including PI # 1, who presented to the hospital ED on 8/3/23, was diagnosed with Major Depressive Disorder and transferred to Hospital B.

Findings Include:

Refer to A 2409 for findings.

Based on an observational tour, review of medical records, hospital policies and procedure, physician on-call schedules, medical records (MR), Geriatric and Adult psychiatric unit bed census reports, Ambulance Run Report, and interviews, it was determined the hospital failed to minimize the risks to the individual's health by failing to provide medical treatment within its capacity, as this resulted in an inappropriate transfer of Patient Identifier (PI) # 1.

This affected PI # 1, one of three psychiatric patients reviewed who were transferred from the facility and had the potential to negatively affect all patients who require psychiatric services.

Findings include:

Hospital Policy: EMTALA (Emergency Medical Treatment and Labor Act) Policy
Policy Number: 13629588
Revised Date: 5/23

1. EMTALA Compliance Policy.

1.1. General Information:

...IV. It is the policy of this hospital that all employees and medical staff shall comply with the provisions of this law...

1.3 Procedure:

...IX. All patient transfers...shall be made consistent with the patient transfer policy of this facility.

...1.5 Capabilities: Capabilities encompass the scope of...privileged medical staff...of this hospital as it pertains to the nature, scope, and degree of services that can be provided by this hospital...

2. Areas of Practice: ...Psychiatry.

3. Capacity: ... Capacity is the physical ability of the facility to accommodate the patient, including bed availability, staff ability, or availability...

9. Psychiatric Assessment.

...A. Patients presenting with symptoms of psychiatric disturbances are considered to have an Emergency Medical Condition under federal law...

9.1...III. Transfers of mental health patient are governed by the same hospital rules as any other transfer, including...appropriate reasons for transfer...

16.1. Types of Transfers Allowed:

I. A patient shall be provided all necessary and appropriate stabilizing care within the capabilities of this facility, and shall not be transferred...except in compliance with...the following procedures:

16.2. Transfers by Certification Procedure:

I. The attending physician has...determined that the patient is in need of services or procedures not within the capabilities of this hospital to provide.

Hospital Policy: Criteria for Admission to the Behavioral Health Units
Policy Number: 10017885
Revised Date: 9/22

Purpose: To implement appropriate admission of patient to the...Behavioral Health Unit...

Inclusionary Criteria:

The patient must be 19 years or older for admission to the Behavioral Health Adult Unit...

Patients must be 55 years or older for admission to the Behavioral Health Geriatric Unit.

Patients may be admitted to the opposite unit if the physician and/or the Treatment team members deem that the patient would benefit more from the program on that unit...


Review of the ED Triage dated 8/3/23 at 12:23 AM revealed the patient had feeling of hopelessness and depression due to recent loss of two family members. The patient denied suicidal ideation, denied any suicidal planning but stated, "I just don't want to live anymore". The patient's triage (the sorting of patients in an emergency room according to the urgency of their need for care) acuity was listed as 2 (Urgent).
Review of the ED Nursing disposition note dated 8/3/23 at 3:42 AM revealed the patient was transferred to (Hospital B) via ambulance.

The ED Physician note for PI #1 dated 8/3/23 at was reviewed. Review of the medical revealed that PI # 1, a 66-year-old patient who presented to the ED via ambulance on 8/3/23 at 12:22 AM with a chief complaint of Psychiatric Problem. The section of the medical record titled "History of Present Illness" revealed the onset of the patient's illness was 2 days prior to arrival, and the duration of symptoms has been since onset. Further review revealed in part, "The patient is not able to control him/herself. There is a history of depression and anxiety. There is a history of having had a similar problem in the past. The reported diagnosis was Severe Depression ...the patient denies any thoughts of suicide or homicide." The section of the note titled "ROS' (review of systems) revealed in part, "PSYCHIATRIC: Positive for anxiety, depression and lack of self-control. Review of the Physical Examination revealed in part, "Neurological: The patient was oriented to person, place and time ...The patient was not confused ...Psychiatric: Thought was coherent, not delusional, not paranoid, with no flight of ideas and with no rambling conversation. Affect was appropriate, anxious and depressed. There was no visual hallucinations or auditory hallucinations. Insight was normal. Judgement was normal." Further review revealed, "IMPRESSION: MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED." Review of the Transfer Form dated 8/3/23 revealed the reason for the patient transfer as psychiatric services not available at the facility.

Review of the ED Physician disposition note dated 8/3/23 at 2:05 AM revealed the patient was accepted to (Hospital B, Receiving Hospital) for transfer due to the hospital having "limited resources". Review of the medical record revealed no documentation of a psychiatric consult.

Review of the hospital on-call schedule dated 8/3/23 revealed the hospital did have an on-call psychiatrist available to provide a consult for PI # 1. The hospital had the capability to provide medical treatment for PI#1 when she presented to the hospital's ED on 8/3/23.

Review of the Ambulance Run Report dated 8/3/23 revealed EMS (Emergency Medical Services) arrived at Dale Medical Center to transport the PI # 1 to Hospital B, (Receiving Hospital) at 3:29 AM, and received report the patient was severely depressed and stated "(he/she) just doesn't want to be here anymore." PI # 1 arrived at Hospital B at 4:16 AM via EMS.

Review of Hospital B, Receiving Hospital, MR revealed PI # 1 was admitted to the Behavioral Medicine Unit on 8/3/23 for Major Depressive Disorder, Severe, and was discharged on 8/8/23.

Review of the Geri psychiatric unit bed census dated 8/3/23 from 12:22 AM to 3:42 AM revealed the hospital normal staffing ratio of one nurse to six patients and one Mental Health Technician (MHT) to seven patients (depending on observation levels).

Further review of the Geri psychiatric unit bed census dated 8/3/23 from 12:22 AM to 3:42 AM revealed two of the units 12 beds were occupied. Further review revealed the unit was staffed with one Licensed Practical Nurse (LPN) and one Mental Health Technician (MHT) due to the Registered Nurse (RN) scheduled for the unit calling in and the hospital inability to obtain an RN for the shift. The nursing supervisor provided supervision of the unit. The facility had the capacity to admit and treat PI # 1 on 8/3/23.

Further review of the Adult unit bed census dated 8/3/23 from 12:22 AM to 3:42 AM revealed two of the units 13 beds were occupied. Further review revealed the unit was staffed with an RN and two MHT's, of which one MHT was on orientation.

A tour of the Geri Psychiatric Unit and Adult Psychiatric unit was conducted on 9/13/23 at 3:57 PM. A reception desk with video monitoring is centered in between the door of the Geri psychiatric and adult unit. In a L shaped pattern, on the left side of the reception desk is the Geri psychiatric unit behind locked doors and on the right side of the desk is the adult unit behind locked doors.

During the tour, Employee Identifier (EI ) # 2, Chief Nursing Officer, verbalized there was approximately 30 to 40 feet between the Geri psychiatric unit doors and the adult unit doors.

An interview was conducted on 9/13/23 at 10:29 AM with EI # 3, Nursing Supervisor for 8/3/23. EI # 3 verbalized when one of the units, was staffed with only an LPN, an RN would be assigned to either float between the adult and Geri psychiatric units or charge over both units. EI # 3 verbalized if an RN, was floating or the charge nurse for both the geropsychiatric and adult units, a new patient would be able to be admitted to the units and the nursing staff ratio would be a one nurse to a seven-patient ratio. EI # 3 verbalized the nursing supervisor would look at both units instead of only one to determine the staffing ratio, when an RN was floating between the units or charging over both sides of the units.

An interview was conducted on 9/13/23 at 4:12 PM with EI # 1, Director of Quality and Risk, who confirmed the hospital did have a psychiatrist on-call for 8/3/23 and the Geri psychiatric unit did have open and available beds. EI # 1 further verbalized the reason PI # 1 was not admitted to the Geri psychiatric unit was due to the unit not having a RN the night of 8/3/23.

The facility failed to ensure that their own policies and procedures were followed as evidenced by failing to admit PI # 1 on 8/3/23 for psychiatric treatment when they had the capacity and capability to treat the patient but transferred the patient to Hospital B for admission. Additionally, the hospital failed to minimize the risks to PI # 1's health by failing to provide medical treatment within its capacity, which resulted in an inappropriate transfer for PI # 1.