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Based on record review and interview the facility staff failed to appropriately transfer patients receiving care in the Emergency Department (ED) as per EMTALA (Emergency Medical Treatment and Active Labor Act) regulations in 1 of 20 medical records reviewed (Patient (Pt) #1), in a total sample of 20 medical records reviewed.

Findings include:

The facility staff failed to appropriately transfer a patient receiving care in the Emergency Department (ED) as per EMTALA regulations. See Tag A-2409

Based on record review and interview the facility staff failed to appropriately transfer a patient receiving care in the Emergency Department (ED) as per EMTALA (Emergency Medical Treatment and Active Labor Act) regulations in 1 of 20 medical records reviewed (Patient (Pt) #1), in a total sample of 20 medical records reviewed.

Findings Include:

Review of policy and procedure #2855 titled, "ED Patient Transfers to and from Froedtert" last reviewed 02/01/2023 revealed the following:
1. An appropriate transfer to a medical facility is a transfer:
a) "In which the transferring hospital provides the medical treatment within its capacity that minimizes the risk to the individuals health..."
b) "In which the receiving facility: 1) Has available space and qualified personnel for the treatment of the individual. 2) Has agreed to accept the transfer of the individual and to provide appropriate medical treatment."
c) "In which the transferring hospital sends to the receiving facility: 1) All medical record copies related to the emergency condition for which the individual has presented... 2) Completed Physician's Certificate of Transfer Form."
2. "Patients that require services and/or a level of care that cannot be provided at (hospital) but are available at another facility will be transferred to another facility. The attending physician is responsible to make the determination of appropriateness of transfer and initiate arrangements with a physician at the receiving facility.
3. "Patients going to another medical facility must be managed as formal transfers and not as discharges."
4. "The transfer of an unstable individual may take place only when the individual...requests a transfer to another medical facility in writing after being informed of the hospital's obligation under EMTALA and of the risks of transfer."
5. "After securing an accepting physician and accepting facility agreement of transfer, the transferring RN (Registered Nurse) and physician must call report to the receiving facility communicating the reason for the transfer, the patient's condition at the time of the transfer, available history, observation of signs or symptoms, preliminary diagnosis and results of any tests."
6. "The transferring physician will complete the following physician section of the Physician's Certificate of Transfer Form: a. Medical condition. b. Reason for transfer. c. Risks and benefits for the transfer. d. Mode/support/treatment during transfer...e. receiving facility and individual with physician certification of an appropriate transfer by signature, date and time. f. Patient consent for the transfer..."
7. The transferring RN will complete the nursing section of the Physician's Certificate of Transfer Form..."
8. "A member of the Care Management Team will fax clinical records to the receiving facility, which include the history and physical, Provider notes, RN notes, copy of procedures and test results, and/or labs. A copy of the Physician's Certificate of Transfer must also be sent to the receiving facility..."

ED (Hospital #1) Medical Record Review:
Review of Pt #1's ED timeline revealed Pt #1 arrived in the ED on 09/30/2023 at 9:33 PM with the arrival complaint of "Suicidal Voices"; Pt #1 was discharged with police on 10/01/2023 at 6:36 AM.

Review of Pt #1's ED Triage Notes dated 09/30/2023 at 9:36 PM revealed, "Patient ambulatory to triage with complaints of hearing voices for the past 2 weeks. Patient reports the voices are telling him to kill himself. Patient reports he lives in a house with guns that are not locked up. Patient reports previous suicidal attempt. On meds (medication), reports 'I feel like they are not working anymore' denies alcohol. + (positive) marijuana."

Review of Pt #1's ED Care Timeline revealed the following documentation:
09/30/2023:
-At 9:49 PM: Pt #1 roomed in the ED.
-At 9:54 PM: Pt #1's Columbia Suicide Severity Risk assessment revealed Pt #1 replied, "Yes" for the question "Wished to be Dead,"; "Yes" for having "Suicidal thoughts for the past month"; "Yes" for "Suicidal thought method"; and "Yes" for "Suicide Intent with specific plan." Level of Risk per Screen was documented as "High Risk."
-At 10:07 PM: ED notes revealed Room Safety Interventions included; "1:1 sitter at bedside until provider evaluation & safety order placed."
-At 10:19 PM: Orders Placed to consult Psychiatry.
-At 11:13 PM: Initial Provider Assessment completed by Physician A.
-At 11:42 PM: Order Placed Unsafe Behavior Precautions changed to "Moderate Risk" 30 minute checks and Telemetry (heart monitoring) observation.
10/01/2022:
-At 2:22 AM: ED Notes Addendum documented by Social Worker (SW) D revealed, "SW received handoff from ED Psychiatrist. Pt is a 35 y/o (year old)...who present to ED for concern of SI (suicidal ideations) with plan. Per ED Psychiatry, pt appropriate for inpatient treatment, however pt would also be appropriate for dc (discharge) home if pt able to safety plan at later time throughout night." Review of SW D's note revealed that referrals were made to 3 separate psychiatric facilities but "they do not accept Pt #1's insurance"; Per SW D's note 2 other hospitals, "did not take referrals at this time of night."
-At 5:15 AM: SW D's note revealed, "SW updated pt (Pt #1) and MD (medical doctor) on lack of bed availability. SW attempted to safety plan with pt. Pt reports that he does not have current outpatient services....Pt reports he has not used any substances besides marijuana lately. SW inquired if pt felt the marijuana worsened his SI and if being in the ED for the extended time period has helped his symptoms at all. Pt denied that drug use contributed to his SI and stated that he felt the same. Pt reported he is unable to safety plan at this time stating he feels like he would still shoot himself with his roommate's gun if he left." Per SW D's note, "MD updated on pt's inability/unwillingness to safety plan at this time and inquired about ED hold. SW explained pt not appropriate for ED hold as he is voluntary for treatment. MD requested police come do a chapter evaluation (to detain pt involuntarily for imminent safety risk to self or others) to ensure. HUC (health unit coordinator) to call Tosa PD (police department) to complete chapter hold eval (evaluation)."
-At 5:45 AM: "Discharge Disposition Selected" documented by Physician A revealed, "ED Disposition set to Discharge."
-At 5:48 AM: ED notes documented by RN C revealed, "AVS (After Visit Summary) Printed."
-At 6:10 AM: ED notes documented by RN C revealed, "(Police) at bedside, will transport patient to (Psychiatric Hospital)."
-At 6:36 AM: ED notes documented by RN C revealed, "Patient Discharged."

Review of Pt #1's Discharge Information revealed the "Discharge Disposition" documented was "Psychiatric Hospital."

Review of Pt #1's ED Provider Notes documented by Physician A on signed on 10/02/2023 at 11:03 PM revealed, "...Per Social Worker, patient cannot be chaptered due to being voluntary, and unfortunately no beds are available that accept (Pt #1's) insurance. I requested officers to come speak with the patient given my concern about (Pt #1's) wellbeing and making direct statement to nursing that he will go home and shoot himself. (Pt #1) is not willing to make a safety plan. Officers informed nursing that they would drive (Pt #1) over to (Psychiatric Hospital) if (Physician A) discharged the patient. The patient has no medical reason to be admitted. Given this and inability to chapter (to detain pt involuntarily for imminent safety risk to self or others) the patient, and the patient is voluntary, patient was discharged from the ED.

Review of Physician A's ED Course notes documented on 10/1/2023 at 5:46 AM revealed, "Officers at bedside, state they will take (Pt #1) to (Psychiatric Hospital)."

Review of Pt #1's After Visit Summary (AVS) dated 10/1/2023 at 5:48 AM revealed Discharge Instructions including, "Your Diagnosis is: Thoughts of suicide with plan."; "Return to the Emergency Department for if symptoms worsen or for any other concerns."; "Medications: These are your new prescriptions: None; These Medicines that you take now have been changed: None"...."Additional Instructions: None"

Psychiatric Hospital (Hospital #2) Medical Record Review:

Review of Pt #1's ED timeline at the Psychiatric Hospital revealed Pt #1 arrived in the ED on 10/01/2023 at 6:50 AM (14 minutes after discharge from Hospital #1). Per Arrival Documentation, Police Officer was present and Pt #1 was seeking "Voluntary Behavioral Health Treatment." Pt #1 was discharged home on on 10/01/2023 at 8:46 AM.

Review of Pt #1's Psych Evaluation dated 10/01/2023 at 8:30 AM revealed, "The pt was brought here voluntarily from (Hospital) ED, but no doc-to-doc (doctor to doctor call) so unclear how that was appropriate."

Interviews at Hospital #1:

During interview with Clinical Nurse Specialist (CNS) F, Accreditation Coordinator (AC) G, and AC H on 10/18/2023 beginning at 11:30 AM, while reviewing Pt #1's medical record, the staff confirmed that there was no documented evidence of the following: A Physician Certification for Transfer Form completed by the physician and RN as per policy including but not limited to, reason for transfer, risk and benefits of transfer explained, and patient's consent for transfer; evidence that the receiving hospital accepted the transfer of Pt #1; documented evidence of the Physician and RN calling report to the receiving facility as per policy; and documented evidence of Pt #1's medical records being sent to the receiving facility as per policy.

Per interview with Physician A on 10/18/2023 beginning at 3:00 PM, Physician A stated that Pt #1 was not agreeable to a Safety Plan and there were no hospitals able to accept Pt #1 either due to bed capacity or insurance issues. Physician A stated that hospital staff contacted the Police Department to come talk to Pt #1 and determine if Pt #1 could be placed under a Chapter 51 Hold; Per Physician A this would open up more options to transfer Pt #1 to an inpatient mental health hospital. Physician A stated that Police Officers arrived and evaluated Pt #1, and determined Pt #1 could not be placed under a Chapter 51 Hold because Pt #1 was voluntary and agreeable with an inpatient admission. Per Physician A, the Police Officer suggested that Physician A discharge Pt #1 and the Police Officers would transport Pt #1 to the Psychiatric Hospital's ED. Per Physician A, he/she felt that there were no other options and that Pt #1 was not safe to go home. Physician A stated that he/she did not call the Psychiatric hospital to ensure the hospital was able to accept Pt #1, nor did Physician A call report to a physician at the Psychiatric hospital. Physician A confirmed that he/she did not complete a Physician Certification Transfer Form and treated Pt #1's disposition as a discharge.

Per interview with RN C on 10/18/2023 beginning at 2:35 PM, RN C stated that she/he was Pt #1's nurse at the time of discharge. Per RN C, there were no hospitals able to accept Pt #1 for a psychiatric inpatient admission, so the Police Officer informed RN C to have Physician A discharge Pt #1 and the Police Officer would transport Pt #1 to the mental health hospital's ED. RN C stated that Physician A did not feel Pt #1 was safe for discharge home but agreed to discharge Pt #1 with the Police Officers. RN C stated Pt #1's disposition was handled like a discharge so she/he did not call the receiving hospital to give RN to RN report and did not complete the Physician Certification Transfer Form. RN C stated she/he printed out the AVS (discharge instructions) and provided that to the Police Officer. RN C stated that Pt #1's medical records were not sent to the mental health hospital.

Per interview with SW D on 10/19/2023 beginning at 11:44 AM, SW D stated that if a patient is suicidal it is not appropriate to discharge a patient unless they can commit to a Safety Plan. SW D stated that Pt #1 was not agreeable to a Safety plan. SW D stated that she/he tried to get Pt #1 accepted as an inpatient psychiatric admission to multiple hospitals, but either the hospitals were full or did not accept Pt#1's insurance.