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Based on staff and guardian interview and review of medical records and policies, it was determined the CAH failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24. The CAH failed to ensure an appropriate transfer was performed 1 of 5 patients (#5) whose records were reviewed. This resulted in the inability of the hospital to ensure psychiatric patients were transferred in a safe manner. Findings include:

The policy "Emergency Medical Treatment and Labor Act (EMTALA)," not dated, defined an appropriate transfer as "For psychiatric conditions: if the person is not in danger of harming themselves or others, or they are protected from harming themselves or others." The policy did not define what a safe transfer included nor did it state how staff would achieve a safe transfer. Refer to A2409 as it relates to the failure of the hospital to provide an appropriate transfer.

The hospital failed to develop and implement policies to ensure compliance with the requirements at 42 CFR Part 489.24.

Based on staff and guardian interview and review of medical records and policies, it was determined the CAH failed to ensure an appropriate transfer was effected for 1 of 5 patients (#5), who were transferred and whose records were reviewed. This resulted in injury to the patient and the potential for an exacerbation of symptoms in all psychiatric transfers. Findings include:

The CAH failed to effect the transfer of Patient #5 through qualified personnel and used an alleged perpetrator to transport her to a receiving hospital.

The policy "Emergency Medical Treatment and Labor Act (EMTALA)," not dated, defined an appropriate transfer as "For psychiatric conditions: if the person is not in danger of harming themselves or others, or they are protected from harming themselves or others." The policy did not address what persons were safe to transport a patient to a receiving health care entity.

Patient #5 was a 15 year old female who presented to the CAH's ED on 10/16/17. The triage nursing note, dated 10/16/17 at 2:30 PM, stated Patient #5's chief complaint was suicidal ideation. She was eventually transferred to a psychiatric hospital 294 miles away over mountain roads on 10/19/17.

Patient #5 remained an ED patient throughout her stay. A physician progress note, dated 10/17/17 at 12:00 noon, stated Patient #5 could not be admitted as an inpatient because of the CAH's policy.

A "Triage Report" by the RN, dated 10/16/17 at 3:02 PM, stated Patient #5 threatened to kill herself by overdosing on pills or by hanging herself.

The first physician progress note, dated 10/16/17 at 2:20 PM, stated Patient #5 said "...if she has to go home with Dad, she will kill herself. None of the physician notes on 10/17/17 and 10/18/17 mentioned Patient #5's psychiatric status. The final physician note, dated 10/19/17 at 5:45 AM, stated the plan was for the father to transport Patient #5 to the receiving hospital. The note stated, if the father did not arrive Patient #5 would be placed in foster care.

A History and Physical by the physician, dated 10/16/17 at 2:23 PM, stated Patient #5 said "...her father punched her, thrown objects at her, and other forms of physical abuse that he always claims he does not remember." None of the physician notes stated Patient #5 was safe to transfer with her father.

The physician placed Patient #5 on suicide precautions on 10/16/17 at 3:48 PM. The suicide precautions remained in place during her entire stay.

A "CASE MANAGEMENT" note, dated 10/16/17 at 9:10 PM, stated Patient #5's father said she had been in several psychiatric hospitals. He stated she had been sexually assaulted several times and used drugs, including recent methamphetamine use. The father stated he had a fight with Patient #5 the night before. He stated he left the house and when he returned she was gone. He stated she called police who took her to her grandfather's house. He stated she then had a fight with her grandfather when she could not smoke in the car. He stated she went to school and told the counselor she was suicidal. The same note stated Patient #5 stated if she went home with her father she would hang herself. The note stated Patient #5 said last night her father pushed her down, told her he hated her and wished she had never been born, and called her a whore who caused herself to get raped. Patient #5 stated she got marijuana, alcohol, and other drugs from her friends and stole morphine from her grandmother.

A "CASE MANAGEMENT" note, dated 10/16/17 at 9:11 PM, stated Patient #5's father expressed concern about cutting behavior.

A nursing progress note, dated 10/16/17 at 4:10 PM, stated Patient #5 reported she had unprotected sex with 53 partners and had symptoms of a sexually transmitted disease.

A "CASE MANAGEMENT" note, dated 10/16/17 at 7:13 PM, stated Patient #5's father and grandfather met with staff. The note stated the father and grandfather became upset and accused staff of not listening to them. The note stated staff felt threatened and called the police to intervene.

An untitled transfer form, dated 10/18/17 at 11:15 AM, stated Patient #5's diagnosis was "Suicidal Ideation." A preprinted box was checked that stated, "Patient Stable. The patient had been examined and any medical condition stabilized such that, within reasonable clinical confidence, no material deterioration of this patient's condition is likely to result from or occur during transfer." The box was checked on the form that stated the transfer was "Medically-Indicated." The box was checked on the form that stated the mode of transfer was "Private Car."

The transfer form was completed the day before the transfer.

After the transfer form was completed, a "CASE MANAGEMENT" note was completed by the MSW on 10/18/17 at 12:31 PM. The "CASE MANAGEMENT" note stated Patient #5 told with the MSW about feeling suicidal because of how her father treats her. The note stated Patient #5 talked about nude pictures of herself being distributed by her boyfriend. The "CASE MANAGEMENT" note stated police were notified and Patient #5 then reported the boyfriend for potentially distributing child pornography. The "CASE MANAGEMENT" note stated the MSW then filed a CPS report due to Patient #5's complaints of the father calling her names and shoving her. The "CASE MANAGEMENT" note stated Patient #5 said she feels like she is possessed by Satan.

A "CASE MANAGEMENT" note, dated 10/18/17 at 8:44 PM, stated the MSW called the police to complain Patient #5's father would not transport her to the receiving hospital but would not place her with anyone else. The note stated the hospital then received a call that the father was angry because the police were called and the father refused to come to the hospital that evening. The father stated he thought the hospital had a no trespass order against him by the CAH. The note stated the MSW invited the father to come to the CAH. The note stated the police then threatened the father with placing Patient #15 in foster care if the father refused to "...work toward getting her to [the receiving hospital." Eventually, Patient #5's father agreed to transport her to the receiving hospital at 6:00 AM on 10/19/17. The note stated the MSW informed Patient #5 of the plan. The notes stated Patient #5 became tearful, saying she would have to go home with her father and be suicidal again. She stated she "...steals marijuana from him and that he has done acid with her at parties. She also reports she is tired of his abuse and comments blaming her for being raped."

The final nursing note was dated 10/19/17 at 6:11 AM. It stated Patient #5's "...father arrived to take [her] to [the receiving] hospital. [Patient] given Xanax per request and breakfast prior to transfer." There was no documentation stating Patient #5's grandfather was present to accompany the father and the patient. No documentation was present regarding what possessions Patient #5 had or what possessions were returned to her on discharge.

None of Patient #5's Physician notes documented that she was psychiatrically stable. No assessment of Patient #5's psychiatric status was documented after the transfer form was completed. No documentation was present stating Patient #5 was safe to travel to the receiving hospital without harming herself or others.
There was no reassessment of the safety of the transfer after the transfer form was signed 19 hours earlier.

Patient #5's father was interviewed on 10/27/17 beginning at 4:00 PM. He stated he drove his daughter from Gritman Medical Center to the receiving hospital on 10/19/17. He stated Patient #5 had a history of mental illness with multiple in-patient stays in behavioral units and psychiatric treatments since she was 12 years old. He stated she had a history of multiple suicide attempts, a history of cutting herself, and a history of multiple rapes. He stated she has multiple mental health diagnoses and has been on multiple psychotropic medications.

Patient #5's father stated during the trip to the receiving hospital, they stopped for lunch and, at that time, she was verbal and pleasant and they continued their trip. He stated upon arrival, she removed her jacket and revealed multiple cuts to both upper arms. The father produced photographs he stated he took at that time and there were what appeared to be more than 25 cuts to both arms. When questioned what she used and when it happened, the father stated she used a razor blade that was in the bag returned to her by the hospital when she left. He stated he thought she cut herself quietly while reclined in the back seat of his car. He also added that both legs had multiple cuts as well.

The Psychiatric Evaluation from the receving hospital, dated 11/20/17 at 1:52 PM, stated on the way to the receiving hospital, Patient #5 "...snuck a razor and significantly cut herself on bilateral forearms and bilateral legs."

No skin lacerations to Patient #5 were documented at Gritman Medical Center. A "SKIN CHECK" at the receiving hospital, dated 10/19/17 at 7:46 PM, documented multiple new lacerations to Patient #5's arms and legs.

The physician who documented on the majority of Patient #5's care and who completed her transfer form was out of the state and was not available for interview prior to the completion of the survey.

The MSW reviewed Patient #5's record and was interviewed on 11/02/17 beginning at 1:05 PM. The MSW stated Patient #5's father wanted her admitted to a hospital in northern Idaho for psychiatric treatment. The MSW stated no beds were available there and a bed was finally found at the receiving hospital. The MSW stated Patient #5's father threatened to just take her to the emergency room at the northern Idaho hospital. The MSW stated she told the father that would not be safe. The MSW stated Patient #5 said her father was physically and emotionally abusive to her. The MSW stated this caused her to notify CPS. The MSW stated while talking to Patient #5's father, he had a threatening posture and he was cussing and screaming at her. The MSW stated this prompted staff to call police because she did not feel safe with the father. She stated Patient #5 felt safe going to the receiving hospital with her father but the MSW said this was not documented. The MSW stated Patient #5's transfer form was written the day before she was transferred. The MSW stated Patient #5 transfer was not reviewed after it was written. The MSW stated Patient #5's belongings were given to her when she left the CAH. The MSW stated the contents of Patient #5's belongings were not documented. The MSW stated Patient #5's grandfather was going to accompany them to the receiving hospital but she said there was no documentation the grandfather actually presented to the CAH with the father for transport. The MSW stated there was no documentation of lacerations to Patient #5's arms or legs while she was at the CAH.

The Director of Quality was also interviewed on 11/02/17 beginning at 1:05 PM. She stated the "Emergency Medical Treatment and Labor Act (EMTALA)" policy did not define what a safe transfer meant.

The CAH failed to effect an appropriate transfer that resulted in Patient #5 harming herself.