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Based on interview, document and record review, the facility (Hospital A) failed to report an inappropriate transfer of Patient 1 from another acute care facility, (Hospital B). Hospital B was informed by Hospital A, that Patient 1 could not be accepted as a transfer because Hospital A's Emergency Department (ED) was on "bypass status" (unable to accept incoming ambulance patients due ED saturation and unavailable resources). Hospital B transferred Patient 1 to Hospital A's ED, despite Hospital A's bypass status.

Findings:

An investigation and record review was initiated on 5/23/11 at 11:45 A.M.
A review of Patient 1's ED triage record, dated 5/9/11, revealed that Patient 1 arrived to Hospital A's ED via an ambulance on 5/9/11 at 6:11 P.M. Per the record, prior to the patient's arrival at the ED, the patient had been taken to Hospital B (an acute psychiatric facility) on a psychiatric hold status and was "gravely disabled." Hospital B determined that the patient's blood sugar was in the 600 range (normal level less than 120) so the patient was transferred to Hospital A for medical treatment.

A review of Hospital A's ED bypass log was conducted on 5/24/10 at 8:00 A.M. According to the log, Hospital A's ED was on bypass on 5/9/11 from 5:57 P.M. until 7:02 P.M., for a total of 1.08 hours. Patient 1 was delivered by ambulance to Hospital A's ED during that time period at 6:11 P.M.

A joint interview was conducted with the ED Nursing Director, Chief Nurse Officer (CNO), and the ED radio room nurse supervisor, on 5/24/11 at 8:00 A.M. Per the radio room nurse supervisor, Hospital A did accept patient transfers during bypass times, but only with ED physician approval.

Further review of Patient 1's ED record on 5/24/11 at 8:30 A.M., revealed no evidence that a physician at Hospital A's ED accepted Patient 1 as a transfer from Hospital B on 5/9/11 during the bypass period.

On 5/24/11 at 2:00 P.M., an interview was conducted with MD 1, the Assistant Medical Director of Hospital A's ED. MD 1 presented an electronic mail (email) document that he received from MD 2 (another ED physician at Hospital A) on 5/9/11 at 9:50 P.M. Per the email, on 5/9/11 MD 2 informed a physician at Hospital B that Hospital A could not accept Patient 1 as a transfer because there were no available beds. According to the email, the ambulance brought the patient to Hospital A and facility staff were unaware of the transfer. According to the email, after Patient 1 was treated, MD 2 contacted a physician at Hospital B to transfer the patient back to Hospital B. Per Hospital B's physician, Patient 1 had a transfer order to another facility, but a clerical error must have occurred, and the patient was mistakenly transferred to Hospital A.

MD 1 stated that he did not notify Hospital A's regulatory affairs department concerning the unauthorized transfer because he thought it was a miscommunication and unintentional. MD 1 acknowledged that he may have "dropped the ball" by not having the unauthorized transfer reviewed and/or reported.