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Based on medical record review, review of facility policy, and interview, the facility failed to provide an appropriate transfer for one patient (#7) of twenty sampled patients.


Refer to A-2409 for failure to provide an approprite transfer.

Based on medical record review, review of facility policy, and interview, the facility failed to provide an appropriate transfer for one patient (#7) of twenty sampled patients.

The findings included:

Patient #7 presented to the facility's Emergency Room on April 10, 2013.

Medical record review of an Initial Interview dated April 10, 2013, at 10:17 a.m., revealed, "Chief Complaint: pt (patient) here co (complains) stomach pain for 2 months. co (complains of) pain in (patient's) LUQ (left upper quadrant)...Triage time: (10:05 a.m.)."

Medical record review of a Nursing Note dated April 10, 2013, at 11:35 a.m., revealed, "...call from Radilogy stating pt. pulled out IV (Intravenous access device)..."

Medical record review of a Nursing Note dated April 10, 2013, at 1:10 p.m., revealed, "...sister and brother in law concerned stating pt is seeing and hearing voices from the walls and vents in the last couple of weeks. Also not letting mother or anyone else out ot the room stating they are contaminated with radiation poisening (poisoning) from (patient's) x/rays...refusing to go to mental health facility suggested by...primary MD (Medical Doctor)."

Medical record review of an Emergency Room Provider Record dated April 10, 2013, revealed, "...Discussed with...Crisis Response...Clinical Impression Psychosis with Paranoid Ideations..."

Medical record review of a Nursing Note dated April 10, 2013, at 1:40 p.m., revealed, "Pt voided but dropped cup in toilet. Pt dressed. Instructed not to leave until d/c'd (discharged). Dr (doctor) speaks to (Hospital #1) Crises (Crisis)." Medical record review of a Nursing Note dated April 10, 2013, at 2:08 p.m., revealed, "(Doctor) signs CON (Certificate of Need for Emergency Involuntary Admission). Mobile Crises notified. States may be a while before arrival."

Medical record review of a CON dated April 10, 2013, at 2:09 p.m., revealed, "...hallucinatory and is unable to care for self...is not evaluating and dealing with reality at present...and...needs evaluation and supervision and treatment...Family does not feel can stay at prsent living situation..."

Medical record review of a Nursing Note dated April 10, 2013, at 6:20 p.m., revealed, "Pt refuses to speak with Crisis."

Medical record review of a Mobile Crisis Response Team Assessment dated April 10, 2013, revealed, "...Date of Assessment and time arrived and time left 4/10/13..." Continued review revealed no documentation regarding time of arrival or departure. Continued review revealed, "...presented in irritable mood flat affect. Extreme paranoia...uncooperative and unwilling to participate in the interview...family reported a recent increase in sx (symptoms) of paranoia...delusional thinking. The (patient) has put (patient's) frail elderly mother at risk for harm due to this...The attending Dr (doctor) has designated the (patient) for involuntary IP tx (inpatient treatment)...agrees to this disposition...has been referred for IP mental health tx..." Continued review revealed no documentation regarding the accepting facility and included, "...If referral is made: Accepting Facility..."

Medical record review of a Nursing Note dated April 10, 2013, at 6:30 p.m., revealed, "Crisis attempting placement." Medical record review of a Nursing Note dated April 10, 2013, at 6:35 p.m., revealed, "Crisis still awaiting admission to (Hospital #1)..." Medical record review of a Nursing Note dated April 10, 2013, at 7:00 p.m., revealed, "(Hospital #1) denied is trying (Hospital #2)..." Medical record review of a Nursing Note dated 10:05 p.m., revealed, "...called back acceptance to (Hospital #2)..."

Medical record review of a Patient Transfer Form dated April 10, 2013, revealed, "...Name of destination hospital: (Hospital #1)...Accepted by...Crisis Response...Accepting M.D. (Medical Doctor): (...Treatment Ctr (center- a treatment center affiliated with Hospital #2)..." Continued review revealed no documentation regarding the accepting physician and included, "Management of Information Report given to (Treatment Center) By...Crisis Response..."


Review of facility Policy Number: 3.022 dated September 13, 2005, revealed, "...Transfer Prior to Stabilizing an Individual with an Emergency Medical Condition (EMC)...An individual with an EMC...must be stablized prior to transfer, unless...A licensed physician evaluates the individual and signs a certification...benefits reasonably expected from the provision of the appropriate medical treatment at another facility outweigh the risks to the individual's medical condition from effecting the transfer...Transfer of Individuals After Stabilization...Transfer Procedures...Acceptance by receiving Hospital and receiving physician. Prior to transfer the receiving hospital and receiving physician must consent to the tranfer of the individual and agree to provide appropriate medical treatment..."

Telephone interview with the facility's Chief Nursing Officer on July 2, 2013, at 10:30 a.m., revealed the facility followed a transfer process determinded by a Crisis Response Team (CRT) and the CRT was responsible for implementing arrangements for transfer including phone calls and other communication with the receiving hospital. She stated, "...What's missing is probable arrangement of placement. CRT person left facility without knowing where patient is (was) going."

Telephone interview with the Director of Crisis Services for the facility on July 2, 2013, at 12:24 p.m., revealed CRT did not document the name of an accepting physician responsible for care at the receiving facility and confirmed the facility had failed to provide an appropriate transfer for Patient #7 on April 10, 2013.