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Based on record review and interview, the facility staff failed to ensure that patients with psychiatric diagnoses have been stabilized prior to being transferred to alternate facilities for care for two of 20 patients reviewed Patient #1 and 11) and that transfer forms are individualized to reflect the specific risks and benefits in 5 of 6 (emergency room psychiatric cases that were transferred out) out of a total of 20 records reviewed (Patient's #1, 11, 13, 15 and 17).

Findings include:

The facility staff failed to ensure that patients with psychiatric diagnosis have been stabilized before being transferred and that transfer forms are individualized to reflect specific risks and benefits in 5 of 6 (emergency room psychiatric cases that were transferred out) out of a total of 20 records reviewed (Patient's #1, 11, 13, 15 and 17). See tag C2409.

The facility staff failed to ensure that psychiatric patients were stable for discharge and/or transfer and that there was complete documentation and evaluation on patients transfers in 2 of 20 records reviewed (Patient #1 & 11). See tag C2407.

Based on record review and interview the facility staff failed to ensure that patients were stable for discharge and/or transfer and that there was complete documentation and evaluation on patients transfers in 2 of 20 records reviewed (Patient #1 & 11).

Findings include:

The facility's policy titled "Emergency Medical Screening, Treatment, Transfer and On-Call Roster" #755, dated 5/2/17, was reviewed on 6/26/18 at 10:50 AM. The policy revealed, in part, "STABILIZATION: 1. Any individual experiencing an emergency medical condition must be stabilized prior to transfer or discharge. 2. "Stabilization" is achieved when material deterioration is unlikely to result from the transfer or discharge of the individual...TRANSFER: 1. The transferring physician or designated hospital employee shall obtain the consent of the receiving hospital before the transfer of an individual and shall make arrangements for the patient transfer with he receiving hospital. 2. The physician responsible for the care of the patient shall document the individual's condition in the medical record prior to the patient being transferred."

The facility's policy titled "Transfer and Referral Guidelines" #018, dated 1/1/14 was reviewed on 6/26/18 at 11:00 AM. The policy revealed under item B "For transfers from New London Family Medical Center to another healthcare facility including transfers from the Emergency Department: 1. Referrals are made to an appropriate provider and patients are transferred to another facility (the facility designated by the provider accepting the referral) when one or both of the following criteria are met: a. The patient has a medical need which cannot be met at New London Family Medical Center as judged by the attending provider. 2. Patients presenting to the emergency department have a right to a medical screening and are not considered for transfer until that medical screening takes place. 3. Patients are to be stabilized as much as possible prior to transfer...6. The patient is not transferred until a provider agrees to accept the patient at the transfer destination." Under "PROCEDURE" documented "A. 3. The referring/transferring provider contacts the accepting provider and gives a verbal referral prior to the actual transfer...7. A determination is made regarding the appropriate mode of transport; the decision is jointly made by the referring provider, and the patient's RN (registered nurse)."

Patient #1's medical record was reviewed on 6/26/18 at 1:25 PM accompanied by Emergency Room Registered Nurse N. Patient #1 presented to the emergency department on 6/10/18 with spouse as having suicidal ideations and a plan to overdose on sleeping pills. An evaluation was completed by the Waupaca County Crisis staff and was decided the Patient #1 would be voluntarily admitted to a psychiatric hospital. When emergency room staff and Crisis Worker I were unable to find an available bed, Patient #1 was instructed to report to an emergency room at hospital in a different city and "tell them you are suicidal and need help." Patient #1's discharge instructions revealed "None". Physician M documented that "Crisis worker (Staff I) had made a safety plan with patient who will now be discharged with instructions to follow up as planned. [He/she] is instructed to proceed with [spouse] to a different hospital in [city] to attempt self-admission through the emergency room."

There was no documentation that Patient #1 was stable and transferred to another facility, physician to physician or nurse to nurse contact for transfer and was discharged with presenting symptom (suicidal ideation) present and told to go to a different (city) emergency room for care. These findings were discussed with and confirmed per interview by Emergency Department Manager A. on 6/27/18 at 10:35 AM.

Patient #11's medical record was reviewed on 6/26/2018 at 12:45 PM accompanied by Informatics Registered Nurse L. Patient #11 presented to the emergency department on 4/18/2018 with suicidal ideations and a plan to hang her/himself. The emergency department provider's plan for discharge revealed, "[Gender] is medically clear and stable. We are now attempting to find appropriate transfer to an inpt (inpatient) setting, ideally to [facility name], via voluntary private transfer." An ED (emergency department) Note entered by Registered Nurse N on 4/18/18 at 5:55 PM indicated that a crisis center was contacted for assistance with psychiatric inpatient placement and the crisis center denied assistance due to being voluntary status then goes on to reveal that placement was secured and patient was "transferred" via personal auto.

There was no documentation from the facility staff documentation to indicate if the psychiatric condition was stable upon transfer or if Patient #11 had contracted for safety (an agreement made not to cause harm to self or others) until an inpatient admission could be completed. The transfer form lists the "Benefits of Transfer" as "specialized services/equipment at receiving facility." The "Risks of Transfer" are listed as "deterioration or worsening condition, accident, delay, death." The risks and benefits were not specific to Patient #11's presenting diagnosis of suicidal ideation. There was no provider to provider contact prior to transfer. These findings were discussed with and confirmed per interview by Emergency Department Manager A on 6/27/2018 at 10:33 AM.

Based on record review and interview, staff failed to ensure that patients with psychiatric diagnoses have been stabilized prior to being transferred to alternate facilities for care and that transfer forms are individualized to reflect the specific risks and benefits in 5 of 6 (emergency room psychiatric cases that were transferred out) out of a total of 20 medical records reviewed (Patient #1, 11, 13, 15, and 17).

Findings include:

The facility's policy titled, "Transfer and Referral Guidelines," #018, dated 1/1/2014, was reviewed on 6/27/2018 at 6:30 AM. The policy revealed in part, "The referring/transferring provider contacts the accepting provider and gives a verbal referral prior to the actual transfer."

The facility's policy titled, "Potentially Suicidal Patients," #063, dated 2/1/2014, was reviewed on 6/27/2018 at 6:35 AM. The policy revealed in part, "Procedure: ...2. The attending physician/designee to initiate psychiatry consult. 3. Obtain a safety contract with patient. 'I promise not to hurt myself.' This can be a verbal contract between the patient and caregiver and documented...The patient writes a narrative contract for safety to include length of contract and specifics of the contract. The caregivers should file this documentation with other documentation in the chart."

Patient #1's medical record was reviewed on 6/26/18 at 1:25 PM accompanied by Emergency Room Registered Nurse N. Patient #1 presented to the emergency department on 6/10/18 with spouse as having suicidal ideations and a plan to overdose on sleeping pills. An evaluation was completed by the Waupaca County Crisis staff and was decided the Patient #1 would be voluntarily admitted to a psychiatric hospital. When emergency room staff and Crisis Worker I were unable to find an available bed, Patient #1 was instructed to report to an emergency room at hospital in a different city and "tell them you are suicidal and need help." Patient #1's "Plan for Discharge Instructions" revealed "None". Emergency Physician M documented that "Crisis worker (Staff I) had made a safety plan with patient who will now be discharged with instructions to follow up as planned. [He/she] is instructed to proceed with [spouse] to a different hospital in [city] to attempt self-admission through the emergency room."

There was no documented safety plan in Patient #1's electronic medical record. There was no documented consult of psychiatrist for assistance with psychiatric inpatient placement, no documented doctor to doctor phone call to emergency room at referred hospital, no documented transfer form, no documented nurse to nurse phone call from facility to the referred hospital emergency room. These findings were discussed and confirmed per interview with Emergency Department Registered Nurse N on 6/27/18 at 1:25 PM.

An interview was conducted on 6/27/18 with Patient Care Manager Emergency Department A to find out what the expectation would be of an Emergency Room physician if a patient actively had suicidal thoughts with a plan and was unable to find an open bed at other facilities. Patient Care Manager Emergency Department A responded "I would expect that they would call the psychiatrist on call and tell them the situation and that on call psychiatrist would accept as a patient and find placement."

Patient #11's medical record was reviewed on 6/26/2018 at 12:45 PM accompanied by Informatics Registered Nurse L. Patient #11 presented to the emergency department on 4/18/2018 with suicidal ideations and a plan to hang her/himself. The "Emergency Department Provider's" plan for discharge completed by Physician O on 4/18/18 at 8:15 PM revealed, "[Gender] is medically clear and stable. We are now attempting to find appropriate transfer to an inpt (inpatient) setting, ideally to [facility name], via voluntary private transfer." An "ED (emergency department) Note" entered by Registered Nurse N at 5:30 PM indicates that a crisis center was contacted for assistance with psychiatric inpatient placement and the crisis center denied assistance due to being voluntary status at 5:46 PM note goes on to reveal that placement was secured.

There was no documentation from Physician O to indicate if the psychiatric condition was stable upon transfer or if Patient #11 had contracted for safety (an agreement made not to cause harm to self or others) until an inpatient admission could be completed and if Patient #11 was stable to transfer by personal auto. The transfer form lists the "Benefits of Transfer" as "specialized services/equipment at receiving facility." The "Risks of Transfer" are listed as "deterioration or worsening condition, accident, delay, death." The risks and benefits were not specific to Patient #11's presenting diagnosis of suicidal ideation. There was no provider to provider contact prior to transfer. These findings were discussed with and confirmed per interview by Emergency Department Manager A on 6/27/2018 at 10:33 AM.

Patient #13's medical record was reviewed on 6/26/2018 at 1:45 PM accompanied by Informatics Registered Nurse L. Patient #13 presented to the emergency department on 4/24/2018 with suicidal ideations. The emergency provider note revealed that Patient #13's plan for suicide was to choke self. Transportation to an inpatient psychiatric facility was completed via law enforcement. Patient #13's discharge plan revealed, "Patient is medically cleared for transport to psychiatric facility..." An additional Medical Clearance letter was written by the provider which revealed, "I have examined this patient and find [her] acceptable for admission to a psychiatric facility. I have no specific suggestions regarding the care of this patient for the condition for which I have examined [gender]"

There was no documentation from the provider to indicate if the psychiatric condition was stable upon transfer. The transfer form lists the "Benefits of Transfer" as "specialized services/equipment at receiving facility." The "Risks of Transfer" are listed as "deterioration or worsening condition, accident, delay." The risks and benefits were not specific to Patient #13's presenting diagnosis of suicidal ideation. There was no provider to provider contact prior to transfer. These findings were discussed with and confirmed per interview by Emergency Department Manager A on 6/27/2018 at 10:35 AM.

Patient #15's medical record was reviewed on 6/26/2018 at 2:33 PM accompanied by Informatics Registered Nurse L. Patient #15 presented to the emergency department on 4/25/2018 with a diagnosis of Schizophrenia and was transferred to an acute inpatient psychiatric facility via law enforcement. The "ED Provider Notes" completed by Physician P on 4/25/18 at 4:48 PM under discharge plan revealed, "Patient is medically cleared for transfer to psychiatric facility. [Gender] is transported via police officer. Bed has been arranged at [facility name]."

There was no documentation from Physician P to indicate if the psychiatric condition was stable upon transfer. The transfer form lists the "Benefits of Transfer" as "specialized services/equipment at receiving facility." The "Risks of Transfer" are listed as "deterioration or worsening condition, accident, delay." The risks and benefits were not specific to Patient #15's presenting diagnosis of Schizophrenia. There was no provider to provider contact prior to transfer. These findings were discussed with and confirmed per interview by Emergency Department Manager A on 6/27/2018 at 10:35 AM.

Patient #17's medical record was reviewed on 6/26/2018 at 2:55 PM accompanied by Informatics Registered Nurse L. Patient #17 presented to the emergency department on 5/9/2018 with suicidal ideations. The emergency provider note revealed that Patient #17 was displaying unusual behavior, would not stop talking, and was exhibiting flight of ideas. Transportation to an inpatient psychiatric facility was completed via law enforcement. The Emergency Department Course documentation revealed medications Patient #17 was given for demonstrated behaviors, and "I believe this [gender] should be transferred to an in pt psychiatric facility. Crisis team and police agree. No obvious injury from [gender] accident, and no obvious acute, medical condition that would explain [gender] behavior."

There was no documentation from the provider to indicate if the psychiatric condition was stable upon transfer. The transfer form lists the "Benefits of Transfer" as "specialized services/equipment at receiving facility." The "Risks of Transfer" are listed as "deterioration or worsening condition." The risks and benefits were not specific to Patient #17's presenting diagnosis of suicidal ideation. There was no provider to provider contact prior to transfer. These findings were discussed with and confirmed per interview by Emergency Department Manager A on 6/27/2018 at 10:38 AM.

Per interview with Emergency Department Manager A on 6/26/2018 at 3:35 PM regarding documentation of patients presenting with a psychiatric diagnosis being stable but requiring transfer to inpatient psychiatric facilities, Manager A stated, "You're right. They can't [say the patient is stable]. They are medically stable not psychiatrically stable."

Per interview with Director of Nursing C on 6/27/2018 at 9:25 AM regarding provider to provider contact for psychiatric transfers, Director C stated that according to Emergency Department Supervisor E (in a conversation C had with E on the evening of 6/26/2018) the crisis center determines if there is a need for provider to provider contact. When asked what happens if crisis workers are not called or do not assist with arrangements, Director C responded, "Good question."

Per interview with Manager A on 6/27/2018 at 10:30 AM regarding the crisis center determining the need for provider to provider contact for a psychiatric transfer, Manager A shook head no and stated that Manager A was not aware that practice was taking place, "The provider should be calling."