HospitalInspections.org

Based on document review, and staff interview, the hospital staff failed to ensure emergency department staff appropriately transferred one patient (#1) who presented to the emergency department for treatment of a psychiatric emergency, to another hospital with specialized capabilities, out of 60 cases selected for review from December 2009 to February 2010. The hospital staff identified an average of 1878 emergency room visits per month.

Failure to arrange a transfer to another hospital with specialized capabilities could potentially result in patients not receiving appropriate care for their emergency condition, and potentially lead to disability, or loss of limb or life.

Findings include:

1. Review of the policy "EMTALA Transfer and Emergency Examination", reviewed/revised on 2/10, revealed in part, "... Behavioral Health Patients. The [Trinity Regional] Medical center does not have an inpatient behavioral health unit.... the patient will be transferred to an appropriate behavioral health facility, ... "

2. Review of the medical record revealed Patient #1 presented to the Emergency Department (ED) on 2/18/10 at 12:43 PM with a psychiatric emergency. ED staff initially arranged for Hospital B to accept Patient #1 for inpatient mental health care. However, the medical record revealed ED staff instead discharged Patient #1, and Registered Nurse (RN) A documented in the medical record at the time of the discharge, "... [he/she] doesn't know if [he/she] can stay away from the pills [and not take an overdose of medication] when [he/she] gets home."

3. During an interview on 3/17/10 at 2:05 PM, Advanced Registered Nures Practitioner (ARNP) F acknowledged the ED staff did not coordinate an appropriate transfer to a hospital with specialized capabilities to treat Patient #1's psychiatric emergency. Instead, the ED staff discharged Patient #1. The hospital failed to follow their policy, and did not appropriately transfer a patient (#1) who had an unstable emergency condition. Refer to tag A-2409 for further details.

Based on document review, staff interview, and QIO review, the hospital staff failed to appropriately transfer a patient (#1) who presented to the emergency department for treatment of a psychiatric emergency, to another hospital with specialized capabilities, out of 60 cases selected for review from December 2009 to February 2010. The hospital staff identified an average of 1878 emergency room visits per month.

Failure to arrange a transfer to another hospital with specialized capabilities could potentially result in patients not receiving appropriate care for their emergency condition, and potentially lead to disability, or loss of limb or life.

Findings include:

1. Review of the medical record revealed Patient #1 presented to the Emergency Department (ED) on 2/18/10 at 12:42 PM. Registered Nurse (RN) A documented on the "ED Chart Nursing Note" that Patient #1 "took 7-8 Vicodin this [morning], then [took] 6-7 Aleve. [Patient #1] has been having suicidal thoughts [off and on] by [taking an] overdose [of medication]. At 4:50 PM, RN A documented "Call into [name of Hospital B] with all information and [Hospital B] will return [phone] call." At 6:10 PM, RN A documented "[name of RN C] from [name of Hospital B] called, and Dr. [name of Physician D] [is] willing to accept [Patient #1 for inpatient mental health care]." At 6:20 PM, Advanced Registered Nurse Practitioner (ARNP) F documented "[Magistrate E's name] called for committal of patient. [Name of Magistrate E] refused committal. [Magistrate E] stated [the patient's] threat of suicide [is] not enough [evidence] to commit the patient according to guidelines. [ARNP F] voiced concern of [the patient's] threats of self-harm and [the fact Patient #1 lives] alone. [Name of Magistrate E] continued to deny [the] need for transfer/committal to [inpatient] psychiatric care." At 6:45 PM, RN A documented "[Patient #1] getting dressed and informed of discharge. [Patient #1] states to nurse, [he/she] doesn't know if [he/she] can stay away from the pills [and not take an overdose of medication] when [he/she] gets home. [The] nurse informed [the] patient if [he/she] is a harm to [himself/herself] and can't stay away from pills [and not take an overdose of medication], to call 911 for help." Further review of the medical record revealed ED staff completed the transfer paperwork, to transfer Patient #1 to Hospital B, but then completed discharge paperwork for Patient #1 at 7:20 PM. The medical record revealed no documentation ED staff attempted to arrange an appropriate transfer to a hospital with specialized capabilities after Magistrate E refused to order court committal for inpatient mental health care for Patient #1.

2. During an interview on 3/17/10 at 8:10 AM, RN A stated Hospital B initially accepted Patient #1, with the understanding Trinity Regional Medical Center would obtain a court committal for inpatient mental health care for Patient #1. RN A stated other hospitals would not accept Patient #1 without Patient #1 being court committed for mental health care, despite the fact Patient #1 was willing to voluntarily sign into a mental health care unit for inpatient care. Once Magistrate E refused to issue a court committal for Patient #1 to receive inpatient mental health care, RN A called Hospital B, and Hospital B refused to accept Patient #1 without a court committal. Then, RN A stated ARNP F instructed RN A to discharge Patient #1, despite RN A's concerns Patient #1 was not stable for discharge.

3. According to the statutorily required QIO physician peer review conducted on 3/31/10, Patient #1 had an emergency that was not stable at the time of discharge.