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Based on records review and interviews, the facility failed to provide stabilizing treatment to a delusional, post-partum woman, Patient #1, until a bed was available at a local Psychiatric Inpatient facility.

The facility failed to ensure that it followed the appropriate transfer requirements for the delusional, post-partum woman.

When the facility failed to secure acceptance from the recipient hospital because there was no available psychiatric in-patient bed at the time of the transfer request, facility released Patient #1 to a local Emergency Medical Services (EMS) and the Albuquerque Police Department (APD) to transport her to the recipient hospital anyway.

This failed practice exposed Patient #1 to additional psychological trauma while in EMS and/or APD custody.

The findings are:

A. Record review of Patient #1's discharge planner notes indicated no local inpatient Psychiatric facilities had beds available for Patient #1 at the time of transfer.

1. Facility discharge planner notes indicated the following:"Placement had been attempted with two local hospitals and one [farther away]."


B. Record review of EMS transport notes dated 10/06/14 at 7:44 pm indicated that EMS and APD were transferring Patient #1 to the recipient hospital's Emergency Room. There was no psychiatric inpatient bed at the recipient hospital at the time of the transfer and the hospital had not accepted the transfer.


C. Record review of the facility's Physician's Certificate for Emergency Detention indicated that a Psychiatric hold had been placed on Patient #1. The document was signed by a transferring facility Nurse Practitioner. Further review of facility transfer documents indicated no accepting physician had signed off on the transfer.


D. On 11/03/14 at 4:05 pm, during interview, the Risk Manager at the recipient hospital stated, "This is a patient that delivered a newborn on 10/06/14 at 5:00 am at [the transferring hospital]. Apparently she had some kind of psychotic break. She has schizophrenia and was off her meds while pregnant. [The transferring facility] faxed a packet of medical records to the [receiving] Psychiatric Emergency Services at 4:25 pm on 10/06/14. The cover sheet said, 'Please call us when a bed is available.' She had been admitted to [the transferring facility] at 4:10 am and had the baby at 5:00 am. The fax was sent at 4:00 pm. We called the number they gave us at 4:28 pm and left a message. They should have gone through our physician access line and asked for a psychiatrist. The next thing we know is that she was sent to main [the receiving hospital] at 5:33 pm. She was evaluated that night, and was transferred to the [the inpatient psychiatric receiving hospital] at 7:27 am 10/07/14. Beds were available at that time."


E. On 11/04/14 2:00 pm, during interview, the transferring Case Manager/Social Worker stated: "Two people from [the psychiatric consultants] came in to do an evaluation. They stayed about 3 hours. I was making phone calls to facilities on the list that [the consultants] had given to me. I called [the recipient] Psychiatric Hospital who stated they had no beds. [Local facility #2] said they wanted me to fax information and subsequently told me that they didn't feel that she was medically cleared because she had a baby that morning. [A third hospital] wouldn't take her because they felt she should stay in town. At that point, I spoke with [the consulting Psychiatric Service]. They supplied the form that is required for the patient to be picked up by the police. The police officer said that when you have the form, fax it to the northeast substation and the police would come and pick her up. The police came with an ambulance crew, talked her back into her room, strapped her into a gurney, and took her to the ambulance. I did not know where the ambulance was going to take the patient. I informed them of my efforts to transfer her. The police took over managing her at that time."



F. On 11/04/14 at 1:15 pm,Referral, and a facility Social Worker indicated the following: The contractors did the assessment. "She was acutely psychotic. She had been diagnosed for schizophrenia for many years. [The psychiatric consultants] spoke with our on-call psychiatrist. She told me that we need to place the patient on a hold ....When you have a hold, the patient is not allowed to leave. They can be transferred to a psychiatric facility where they will be assessed. If the patient was on the floor [unit], we provide them with a list of facilities where they might be placed ...The hold is a 7-day legal paper and applies if the patient is a danger to self, to others, or gravely disabled (New Mexico statute 43-1-10A4). The physician evaluates the patient during the 7-day period (while in the psych facility) and the physician can extended the time if necessary by going through a mental health court. The patient can be transferred in four-point or chemical restraints of necessary."



G. On 11/04/14 at 1:55 pm, during interview, facility Physician #1 stated, "I was called in as a consultant. I was called when [Patient #1] was aggressive, delusional, and threatening staff. I said she clearly needed inpatient psych help. I signed the necessary forms so that the police could take her to [a local hospital]. I would have signed the five-day hold if [Physician #2] had not signed it."



H. On 11/04/14 at 11:35 am, during interview Assistant Chief Nursing Officer, stated that the recommendation of the [contracting] psychiatry consultant was to ship her to the [a local] Psychiatric Emergency Department for further evaluation.