HospitalInspections.org

Based on review of documentation and interviews with the facility staff, the facility failed to perform an appropriate transfer of Patient #1 to an inpatient psychiatric treatment facility after the patient's medical screening examination and behavioral assessment determined Patient #1 required inpatient psychiatric treatment. The facility failed to notify the receiving hospital of patient transfer or secured an accepting physician at the receiving hospital or complete a memorandum of transfer form.

The findings were:

The facility document titled, "Medical Screening Examination and Patient Transfers," states:
4.2.3 Transferring a patient with an Emergency Medical Condition that has not been stabilized when the transferring physician recommends the transfer: b. If the patient has an Emergency Medical Condition which has not been stabilized, no transfer can take place unless: 2) the physician informs the patient that the medical benefits reasonably expected from the provision of medical treatment at another hospital outweigh the increased risks to the patient (and in the case of labor, to the unborn child) and, therefore, transfer is recommended. The physician's certification is documented on the Memorandum of Transfer form ...

4.2.4 Physicians' responsibilities
b. The transferring physician shall:
4) Prior to transfer, the transferring physician shall secure a receiving physician and a receiving hospital that are appropriate to the medical needs of the patient and that will accept responsibility for the patient's medical treatment and hospital care. The transfer should minimize the risk to the patient.

4.2.5 Hospital responsibilities
a. Arranging for transportation
b. Providing medical records to the receiving hospital
c. Form to be completed
1) Memorandum of Transfer
2) Patient's Request/Refusal/Consent to Transfer


The facility document titled, "Behavior Health Crisis Clinician Provision of Services Plan," states:
4.3.2 ...BHCC [Behavioral Health Crisis Clinician] will assess the patient and communicate the findings and Recommendation to the physician and nurse as appropriate.
4.3.4 Patients who are medically cleared at the conclusion of the Assessment and for whom inpatient behavioral health or substance use disorder treatment is recommended, BHCC will enter a Transfer Center Notification order to initiate the transfer process.


The complete medical record review of Patient #1's ED visit on 7/17/23 was performed on 9/11/23. It was noted that the Behavioral Health (BH) assessment recommended that the patient receive inpatient BH treatment and the ED physician's notes agreed with this finding. No documentation could found for the surveyors to review to indicate that the facility secured a transfer to an accepting hospital or physician; a nurse to nurse or physician to physician report was performed; or a patient's request/refusal/consent to transfer was completed prior to the Patient #1's discharge to police. Patient #1 was transported by the police from transferring hospital to receiving hospital. No memorandum of transfer (MOT) form could be found for the surveyors to review.


Review of the BH [Behavioral Health] Intake Assessment completed on 7/17/23 indicated: "BH Clinician [Staff #8] spoke to provider [Staff #5] via phone. Provider reported Pt would be discharged due to Pt being on APOWW and Venus PD requesting to take Pt to JPS. Pt will not transfer to inpatient BH from TH FW ER."


The surveyors interviewed the ED physician (Staff #5) that took care of Patient #1 on 7/17/23 via email. Below is Staff #5's response on 9/12/23:
Surveyor: What do you remember about this particular patient?
Staff #5: I don't remember anything outside what I recorded in my medical record.

Surveyor: Did this patient have an emergency psychiatric condition?
Staff #5: Yes

Surveyor: If a patient requires a higher level of care or services that are not available or provided by this hospital, what do you do?
Staff #5: I requested a Behavioral Health consultation, who agreed with my assessment the patient needed Inpatient Psychiatric stabilization and treatment, not available at my facility.

Surveyor: Did you initiate a hospital to hospital transfer of this patient? If no, why not?
Staff #5: This process is performed by the THR Behavioral health Transfer Center in our system. I do not know what was done from that standpoint for this patient.

Surveyor: Was a Memorandum of Transfer completed on this patient?
Staff #5: I cannot find any evidence one was done in reviewing the medical record.



The surveyors interviewed Licensed Professional Counselor Associate (Staff #8) that performed Behavioral Health Assessment on Patient#1 on 7/17/23) via email. Below is Staff #8's response on 9/13/23:

Surveyor: What do you remember about this particular patient?
Staff #8: I remember he came in on a APOWW [Apprehension by Police Office Without a Warrant] accompanied by his sister due to a suicide attempt by attempting to cut his wrist. Patient reported he was visiting from a different state for the summer and has death with SI for about a year. He reported feeling hopeless, sad and said he had 1 previous suicide attempt. Patient was recommended for inpatient BH. Pt was to be transferred to another facility for inpatient BH. According to his provider, Pt would be discharged and take to a different facility.

Surveyor: Did this patient have an emergency psychiatric condition?
Staff #8: Yes, attempted to kill himself and endorsed hopelessness and depression.