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Based on medical record review, facility policy review, and staff interview, the facility failed to provide report and documentation of medications administered to a patient upon transfer to the Emergency Department. This affected one patient (Patient #3) and had the potential to affect all patients who required transfer to the Emergency Department.

Findings include:

Review of the medical record of Patient #3 revealed the patient presented to the facility on 05/22/24 at 8:36 PM. She was brought directly from jail and accompanied by police. The intake form noted the patient endorsed suicidal ideations without a plan. The Application for Emergency Admission was signed on 05/22/24 at 1:45 PM. The pink slip revealed the patient represented a substantial risk of physical harm to self as manifested by evidence of threats of, or attempts at, suicide or serious self-inflicted bodily harm and would benefit from treatment in a hospital for her mental illness. The pink slip also revealed the patient had been in jail for six days and had expressed claims of suicidal thoughts, was unable to answer most questions, was having hallucinations, talking to people that weren't there, and answering. The patient was described as paranoid and delusional while in jail.

The Nursing Assessment revealed the patient was severely irritable, anxious, and confused. A staff nurse performed a Broset Violence Checklist as required by facility policy on 05/22/24 at 11:00 PM. The patient scored a total of three with yes answers for boisterous behavior, confused behavior, and irritable behavior.

A nurse's note stated the patient was anxious, agitated, confused, and scored a three on Broset checklist so decision was made to administer emergency medications.

Review of the Medication Administration Record revealed on 05/22/24 at 11:00 PM the patient was medicated with the antihistamine Benadryl 50 mg intramuscular (IM), the antipsychotic Haldol 5 mg IM, and the antianxiety Ativan 2 mg IM, a cocktail known as a B52 (B for Benadryl, 5 for 5 mg of Haldol, and 2 for 2 mg of Ativan).

Staff members performed every 15 minute checks on the patient as ordered by the physician.

A code blue sheet revealed a code was called at 11:35 PM as the patient was found unresponsive. At 11:37 PM, the patient's blood pressure was 82/44, pulse 72, respirations 10, and oxygen saturation 96%. The patient's legs were elevated and cardiopulmonary resuscitation (CPR) was initiated by the code blue team. By 11:41 PM the CPR was complete and the patient was responsive. The code ended at 11:45 PM and Emergency Medical Services (EMS) arrived at this time. The patient was transferred to an Emergency Department approximately two minutes from the facility.

Review of the Transfer Form was silent to medications given prior to transfer or any report given to the receiving hospital. A nursing transfer summary stated only patient was found unresponsive.

Review of the facility policy titled "Transfer to Another Facility," effective 01/2020, revealed emergency transfers to a local Emergency Department are completed when non-psychiatric emergency medical conditions are present. The process of transferring patients to an Emergency Department noted at letter H, the registered nurse will document in the nursing progress notes the name and discipline of the individual in which patient report was given.

Staff A and Staff B were interviewed on 07/02/24 at 3:45 PM. It was confirmed the medical record lacked documentation report was given to the Emergency Department where Patient #3 was transported.