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Based on staff interview, policy review and medical record review, the critical access hospital (CAH's) failed to follow their policy and did not arrange an appropriate transfer for one (Patient #7) of 22 sampled patients presenting to the emergency department requesting care from October 2012 - March 2013. The CAH's failure to follow their policy and arrange an appropriate transfer had the potential to result in risky and unsafe transfers of emergency patients. In the preceding six months, the CAH transferred an average of 10 patients per month.

Findings included:

1. Review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) related policies titled, "EMTALA," and "Guidelines for Patient Transfer," reviewed 03/13, revealed the following:
-The hospital will provide stabilizing treatment within its capacity that minimizes the risks of the individual's health;
-A transfer will not be initiated if the patient may deteriorate from, during or after said transfer;
- The hospital will not transfer patients who are unstable as long as the hospital has the capabilities to provide treatment and care to the patient;
- The patient must be transferred by an appropriate medical transfer vehicle, not a private vehicle unless the patient refuses to be transported by ambulance. The patient's refusal must be in writing;
-The form titled, "Informed Consent to Refuse Form," should be completed and signed by the patient when they refuse either transfer or mode of transfer recommended;
- If a patient is suicidal, or poses a threat to himself or others, he/she shall be detained pending an evaluation by a physician. If detaining is unsafe, notify the police. The patient will be referred/transferred to a psychiatric facility for appropriate screening;
- The patient should be transferred with a BLS or ACLS trained person, or the police department notified for a 96-hour hold.

2. Review of Patient #7's ED record showed the following:
-The patient presented (via friend and private vehicle) to the ED on 12/12/12 at 9:53 PM with a complaint of being suicidal;
-Patient #7 had a traumatic recent past with the death of his mother and step father, and problems with visitation of a child;
-Patient #7 stated he had been depressed and was suicidal, feeling worthless and hopeless;
-Patient #7 wanted to "end it" so a friend brought him to the ED;
-Patent #7 had a means and plan of suicide, "shoot myself in the head," and he owned multiple guns/rifles with ammunition;
-The ED physician examined the patient and diagnosed him with anxiety, depression, and suicidal thoughts;
-The ED physician recommended transfer to another hospital (psychiatric);
-There was no documentation the patient was offered transfer via ambulance;
-The record showed the patient was transferred to a psychiatric facility by private vehicle, and the patient continued to be a risk to himself;
-Staff failed to document refusal of ambulance transfer;
-Staff failed to complete the Informed Consent to Refuse Form.

During an interview on 04/02/13 at 10:50 AM, Staff A, ED Medical Director, stated that typically a psychiatric, or aggressive patient, was evaluated/arrested, and the volunteer fire department or police department was involved in transfer. If the patient refused, the police department should still transfer. Staff A confirmed there was never verification a patient arrived at the recommended transfer site.

During an interview on 04/09/13 at 10:02 AM, Staff R, ED Physician, stated that Patient #7 presented to the ED threatening suicide. The patient talked about hurting himself with a gun. Staff R stated that the patient needed an immediate psychiatric evaluation. Staff R was not aware of the facility's contract with a local mental health center that would come to the ED and provide assistance with evaluation and transfer, at the time of this patient's presentation. The ED Physician failed to to follow the transfer policy and did not arrange an appropriate transfer as required. Refer to C-2409 for additional details.

Based on staff interviews and medical record review, the critical access hospital (CAH) failed to arrange an appropriate transfer for one (Patient #7) of 22 patients reviewed presenting to the emergency department (ED) requesting care from October 2012 - March 2013. The CAH's failure to arrange an appropriate transfer had the potential to result in risky and unsafe transfers of emergency patients. In the preceding six months, the CAH transferred an average of 10 patients per month.

Findings included:

1. Review of Patient #7's ED record showed the following:
-The patient presented (via friend and private vehicle) to the ED on 12/12/12 with a complaint of being suicidal;
-Patient #7 had a traumatic recent past with the death of his mother and step father, and problems with visitation of a child;
-Patient #7 stated he had been depressed and was suicidal, feeling worthless and hopeless;
-Patient #7 wanted to "end it" so a friend brought him to the ED;
-Patent #7 had a means and plan of suicide, "shoot myself in the head," and he owned multiple guns/rifles with ammunition;
-The ED physician examined the patient and diagnosed him with anxiety, depression, and suicidal thoughts;
-The ED physician recommended transfer to a psychiatric hospital;
-The patient refused ambulance transfer, and staff failed to complete the "Informed Consent to Refuse Form;"
-Staff failed to document the refusal of ambulance transfer;
-Staff failed to transfer the patient via the most appropriate medical transfer vehicle and/or provide qualified personnel and transportation equipment;
-The record showed the patient was transferred to a psychiatric facility by private vehicle, even though the patient continued to be a risk to himself;
-Staff failed to contact the contracted psychiatric entity available to assist with arranging a psychiatric transfer;
- Staff failed to transfer Patient #7 with a BLS or ACLS trained person, or notify the police department for a 96-hour hold.

During interviews on 04/02/13 at 10:22 AM and 2:28 PM, Staff C, Chief Nursing Officer (CNO), stated that she was just recently made aware (03/13) of a contract the hospital had with a psychiatric entity since 06/12. The CNO stated that this contract included an evaluation of the patient and assistance with psychiatric transfer and/or placement. The CNO stated that this contract had not been utilized until, approximately 03/26/13 because staff, including herself, were unaware of it and how to contact the appropriate person to initiate care.

During an interview on 04/02/13 at 10:50 AM, Staff A, ED Medical Director, stated that the patient should have been sent by ambulance related to his mental state, "a sticky situation." Typically, a psychiatric, or aggressive patient, was evaluated/arrested, and the volunteer fire department or police department was involved in transfer. If the patient refused, the police department should still transfer. Staff A confirmed there was never verification a patient arrived at the recommended transfer site.

During an interview on 04/02/13 at 12:01 PM, Staff F, ED Registered Nurse, confirmed that suicidal patients are considered unsafe and transport without the appropriate supervision would not be safe. If a patient was considered unsafe, a 96-hour hold should be obtained. Staff F stated that she utilized the contractor for psychiatric services the prior week, but even then contact names and phone numbers were not clear, as well as the scope of services provided.

During an interview on 04/09/13 at 10:02 AM, Staff R, ED Physician, stated that Patient #7 presented to the ED threatening suicide. The patient talked about hurting himself with a gun. Staff R stated that the patient needed an immediate psychiatric evaluation. Staff R failed to insist upon a monitored ambulance transfer for Patient #7 even though he was threatening self-harm.