HospitalInspections.org

Based on policy review, document review, medical record review, and interview, the hospital failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA). This failure potentially placed all patients at increased risk for adverse outcomes.

Findings include:

The emergency department physician did not provide an appropriate transfer for one of one patients (A-2409).

Cross Reference:
489.24 (e) (1)-(2) Appropriate Transfer

Based on policy review, medical record review, and interview in one of one (Patient #1) medical records reviewed, it was determined the hospital did not notify the receiving hospital of Patient #1's transport by the Police Department on a 9.41 (any police officer may take into custody any person who appears to be mentally ill and is conducting themselves in a manner which is likely to result in serious harm to themselves or others to a hospital capable of treating a psychiatric patient) transport and failed to advise law enforcement officers of the medical risks associated with the removal of Patient #1 from the emergency department with a emergency medical condition.

Findings include:

Review of policy "Patient Transfer and Emergency Medical Treatment & Active Labor Act (EMTALA) Compliance", last reviewed November 2021, revealed "All patient transfers must be appropriate, as defined by the following requirements: the transferring hospital provides medical treatment within its capacity, the receiving facility has agreed to accept the patient, the transferring hospital sends to the receiving facility all medical records at the time of transfer, and the transfer is affected through qualified personnel and transportation equipment.

Review on 08/05/24 of the emergency department medical record for Patient #1 revealed the following:
-On 06/08/24 at 04:42 PM, Patient #1 arrived ambulatory to the emergency department with the complaint of "mental issues." At 04:47 PM, Staff (K), Registered Nurse documented Patient #1 presented stating that "the spirits are following me and telling me to leave my body." The voices are telling Patient #1 to harm themself or others. Patient has not been on medications for schizophrenia and only smoked marijuana for the symptoms. Patient #1 was cooperative and was seeking help. At 05:45 PM, Staff (F), Physician Assistant documented the voices are getting louder, more demanding, and Patient #1 wants to hurt themself. Patient #1 had no homicidal thoughts or suicidal plan. At 07:40 PM, Staff (S), Local County Mental Health Counselor performed a mental health examination and recommended further assessment with a possible admission to psychiatric care. At 08:14 PM, Staff (F), Physician Assistant documented Patient #1 was medically cleared and was being prepared for a transport to a psychiatric facility for evaluation.
-On 06/09/24 at 03:00 PM Staff (T), Local County Licensed Clinical Social Worker performed a mental health evaluation and recommended further evaluation and possible admission for psychiatric care.
-On 06/10/24 at 05:44 AM, Staff (J), Registered Nurse spoke with another hospital to transfer Patient #1 and faxed over the medical record. The hospital indicated they did have an open bed if Patient #1 met admission criteria. At 09:40 AM and 12:23 PM, Staff (J), Registered Nurse documented another hospital had not reviewed Patient #1's medical record. At 01:59 PM, Staff (B), Physician documented Patient #1 became increasingly combative and aggressive, verbally yelling and threatening. Patient #1 exited their room and followed someone out of the emergency department exit door. The police were notified and brought Patient #1 back to the emergency department. A decision was made by the police officer to 9.41 Patient #1 and bring the patient to another hospital for psychiatric care. At 02:30 PM, Staff (J), Registered Nurse documented the police spoke with Staff (B), Physician and indicated Patient #1 was placed on a 9.41 and will be transported to a mental health hospital. Patient #1 was discharged in police custody and transported to a mental health hospital. (There was no documentation found which indicated the police had been advised of the medical risks associated with removing Patient#1 from the emergency department with an emergency medical condition).

Interview on 08/05/24 at 10:50 AM with Staff (B), Physician revealed Patient #1 was in the emergency department for two days. Multiple attempts were made to transfer Patient #1 to another facility that had psychiatric care. After a discussion, the police department decided to 9.41 Patient #1 and take them to another hospital with psychiatric care. Staff (B) stated "I did not call the receiving hospital. The emergency department was stressful and busy on 06/10/24. It slipped my mind to call."

Interview on 08/06/2024 at 10:46 AM with Staff (J), Registered Nurse revealed a conversation with the receiving hospital's emergency department registered nurse took place and report on Patient #1 was given. Staff (J) was unable to recall if they called [another hospital] or if [another hospital] called them.

Interview on 08/06/24 at 04:18 PM with Staff (A), Risk Manager verified these findings.