HospitalInspections.org

Based on review of documentation and interviews with the facility staff, the facility failed to perform an appropriate transfer as evidence by a 2 of 20 patients were improperly transferred to Facility B. Patient # 1 required a transfer to a higher acuity facility after slicing his fingers tips off. Facility A was attempting to transfer the patient but two facilities declined. Facility A then called 911 for a transfer for Patient # 1. The facility failed to notify the receiving hospital of patient transfer or secured an accepting physician at the receiving hospital or complete a memorandum of transfer form. Facility B accepted the patient, treated his wounds and discharged him home.
The facility also failed to perform an appropriate transfer of Patient #2 to an inpatient psychiatric treatment facility after the patient's medical screening examination determined Patient #2 required inpatient psychiatric treatment. The facility failed to notify the receiving hospital of patient transfer or secured an accepting physician at the receiving hospital or complete a memorandum of transfer form. Facility B accepted the patient, transferred him to their Psychiatric Emergency Department (ED) and when a bed opened, he was transferred to a Psychiatric Hospital.

The findings include:

Patient # 1 Record Review
Facility A:

The complete medical record review of Patient #1's Emergency Department (ED) visit on 12/15/2023 was performed on 03/04/2024. The facility failed to document how the facility secured a transfer to an accepting hospital or physician; a nurse to nurse or physician to physician report was performed; or a patient's request/refusal/consent to transfer was completed prior to the Patient #1's discharge to police. Patient #1 was transported by the police from transferring hospital to receiving hospital. No Memorandum of Transfer (MOT) form could be found for the surveyors to review.
A review of the document titled, " ED Provider Notes" by Staff # 2, MD-ED on 12/15/2023 at 7:29 PM revealed the following:
Patient (PT) # 1, "is a 57 y.o. male presenting with L[left] hand injury. Pt got his pinky, ring and middle finger (3rd, 4th and 5th digit) caught in an envelope machine. The machine sliced the tips of his fingers off. This occurred 20 minutes [prior to admission] (PTA). He brought the fingertips to the ED with him." ... "The management and plan of care for this patient consists of the following immediate interventions: Transfer to adult facility for xrays[sic], hand consult."

A review of the documents titled "ED Notes" by Staff # 4, RN -ED on 12/15/2023 at 8:35 PM revealed the following ..."patient's hand wrapped with ace wrap and gauze." ... "Dallas fire rescue(DFR) arrived to pick up patient. Finger in possession of fire department in specimen bag on ice. Bleeding of hand controlled at this time."

An interview with Staff # 5, Medical Doctor (MD), ED Medical Director on 03/05/2024 at approximately 10:35 AM revealed the following:
Surveyor: How would you proceed with an adult patient that had their 3rd, 4th and 5th fingertips sliced off and the patient has the fingertips?
MD-ED Director: I would assess to see if the injuries were life threatening, complete an evaluation, have the charge nurse use the Access Center to find a hospital that can treat the patient. If there was a behavioral health symptom, I would call the Mental Health Assessment Team to find the best place for the patient.
Surveyor: Do you have a physician staffed in the Emergency Department (ED) 24 hours a day?
MD-ED Director: We have a minimum of three attending physicians that staff the ED 24 hours a day.
Surveyor: Are you familiar with this case?
MD-ED Director: Yes, I am.
Surveyor: Can you tell me why the patient was not accepted at Parkland or Clements hospitals?
MD-ED Director: Parkland hospital said the injury was not a high enough trauma for them to accept the transfer from us. Clements Hospital said they refused the transfer because the trauma was too great.

Facility B, Patient # 1

A review of the document tiled " ED Notes" by Staff # 11, Registered Nurse-Emergency Department (RN-ED) on 12/15/2023 at 9:03 PM revealed the following:
"Pt brought by DFR from Childrens Medical Center (CMC), not an official transfer or MOT present. Approx. [Approximately] [7:15 PM] 1915 pt's L 3-5th digits partial amputation from an envelope cutter. Last meal was last night. Tetanus updated at CMC. No antibiotics (abx) given."
At 11:22 PM, Staff # 12, MD-ED noted, " Hand evaluated patient - dressed with xeroform and kerlex. will give 1 week of PO [Oral] abx and dc. Will have pt follow up in clinic. All questions answered."


Facility A, Patient # 2:

The complete medical record review of Patient #2's Emergency Department visit on 01/17/2024 was performed on 03/04/2024. It was noted that Staff # 1, ED Provider Note recommended that the patient receive inpatient Behavior Health (BH) treatment and the Staff # 8, DO-Resident, is noted to agree with this finding. No documentation could be found for the surveyor to review and indicate that the facility secured a transfer to an accepting hospital or physician; a nurse to nurse or physician to physician report was performed; or a patient's request/refusal/consent to transfer was completed prior to the Patient #2's discharge to police on emergency detention. Patient #2 was transported by the police from the transferring hospital, Facility A, to receiving hospital, Facility B. No memorandum of transfer (MOT) form could be found for the surveyors to review.

A review of the document titled "Emergency Notes" by Staff # 7, RN-ED on 1/19/2024 at 12:15 AM revealed the following:
" Pt unable to explain what happened to his thumb other than he tried to kill himself. Pt states to this RN that "he wants to be put down" after redirecting pt states that "he wants an injection to end his life", pt has some sort of sediment to entire body, dried blood noted to hands and multiple old marks noted to hands and arms, will need to clean pt up to determine extent of old injuries or scars."

A virtual interview via Zoom with Staff # 1, MD-ED on 03/05/2024 at approximately 12:20 PM revealed the following:
Surveyor: Can you explain your process while with the patient?
Doctor: The patient was brought to the exam room. I talked to the patient and asked him about his history and he was unable to answer my questions. I am not sure if he was unable to answer or if he didn't want to answer. When I examined him originally, he was compliant. I examined him for his original complaint and told the nurse the patient needed to change his clothes to see his lower extremities. I also asked the nurse to clean the cut to the patients finger. I left the exam room, talked with the Resident, and entered orders.

The patient was not fully oriented. He had no account of events. I ordered labs and a CT scan and the patient would not lie down and was brought back to the ED. The patient did not want to comply with medical requests. I talked with the charge nurse about a transfer to an adult facility. Charge Nurse said the patient was trying to elope. Security was called and stayed with the patient so he could be an [Administrative Protective Order] APO and he continued refusing treatment.
Surveyor: Did you sign any papers?
Doctor: Not that I can remember.

Facility B, Patient # 2

A review of the document titled "ED Triage Note" by Staff # 10, RN-ED on 01/18/2024 at 1:55 AM revealed the following:
"Multiple nurses, officers, and MD at bedside. Pt noted to have dried blood on right wrist and fingers. Laceration noted on right thumb. Per officer, patient was dropped off at children's hospital by a UHAL truck for wrist and finger laceration. Was treated at Children's hospital for cuts and brought here for hx of schizophrenia, paranoia related to substance abuse. Denies any substance use today. Pt noted to be cuffed by officer. Pt states "can you take the cuffs off'. Pt is [alert to: self, place, time and situation], AOx4. RR [respirations] even and unlabored. Pt noted to be tachycardic. ABCS [airway, breathing, circulation] intact.

A review of the document titled "ED Triage Note" by Cindy RN -ED on 01/18/2024 at 2:05 AM
"Medicated pt per MAR by Cindy RN on right deltoid
5mg Haloperidol
50mg benadryl
5mg Versed
Added to ED Triage Note: January 18, 2024 at 2:2O AM
2 point restraint applied, notified MD. Pt noted to be calm and cooperative." ... "The patient was monitored at 4:19 and care plan was not met and was revisited. At 6:19 AM Plan of Care was noted as resolved." Staff # 10 reported at 6:24 AM, "Able to comply with instructions; No longer attempting to dislodge essential Medical Device(s). Restraints were removed." ...

A review of the document titled " ED Notes" by Staff # 11, PA-C-Psychiatry on 01/18/2024 at 4:55 PM revealed the following:
Patient # 2, "presented to the ED on 01/18/2024 under emergency detention. The patient was transferred to the psychiatric emergency room on emergency detention.
After being assessed by the psychiatric team, it was determined that the patient required inpatient hospitalization. Based on the patient's behavior and symptoms the patient requires involuntarily hospitalization as they too high risk for voluntarily hospitalization."

On 01/21/2024 at 12:18 PM, Patient # 2 was transferred to a Psychiatric Hospital with transport. It was noted that no available beds were available at Facility B Inpatient or Crisis Residential.

A review of the policy titled "AD 2.29.01 Emergency Medical Treatment (EMTALA) and Patient Transfer - Dallas" revealed the following: pg. 3
Facility A did not follow their own policy. The policy reads:

"Transfer means the movement (including the discharge) of an individual outside a hospital's facilities at the direction of any person employed by (or affiliated or associated with) the hospital but does not include such a movement of an individual who has been declared dead or leaves the facility without the permission of any such person. (Pursuant to state hospital licensing regulations, the movement of a stable patient from the hospital to another medical facility is not considered to be a transfer if it is the understanding and intent of both hospitals that the patient is going to the second hospital only for tests, the patient will not remain overnight at the second hospital, and the patient will return to the first hospital, provided that the patient remains stable during the transfer.) An appropriate transfer occurs when:
a. The transferring hospital provides treatment within its capabilities to minimize risks to
the Patient (and to the unborn child if the Patient is pregnant)
b. The receiving facility agrees to the transfer and has the capability and capacity (bed and staff) to treat the Patient
c. The transferring hospital sends pertinent medical records
d. The transfer occurs with qualified personnel and equipment.
Patient # 1: Patient # 1 was not accepted to two of the facilities contacted by Facility A. Facility A called 911 for a patient transfer for Patient # 1. This is a violation of their policy above.
Patient # 2: Facility A failed to perform an appropriate transfer of Patient #2 to an inpatient psychiatric treatment facility after the patient's medical screening examination determined Patient #2 required inpatient psychiatric treatment. The facility failed to notify the receiving hospital of patient transfer or secured an accepting physician at the receiving hospital or complete a memorandum of transfer form.
.