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Based on observation, interview and record review, the hospital failed to comply with CFR 489.24, the EMTALA requirements when there was no evidence of:

a. Appropriate Medical Screening Exams (MSE) to determine the presence of an emergent medical condition (EMC) and;

b. Medical staff approval of labor and delivery nurses qualified to perform the MSE and;

c. Initial and ongoing assessments, interventions and monitoring to ensure the EMC was stabilized and;

d. Appropriate transfer documents.

Findings:

1. Patient 1, who presented to the Emergency Department (ED) after an alleged suicide attempt, was not assessed and triaged appropriately which resulted in her elopement and subsequent death. (Cross Reference A2406)

2. Sixteen of 22 sampled patients who presented to the ED with psychiatric complaints, including suicidal attempts, suicidal ideation or an altered level of consciousness were not assigned the appropriate level of acuity. (Cross Reference A2406)

3. Fourteen of 30 sampled patients who presented to the ED with psychiatric complaints and one of 30 sampled patients who presented with a medical condition were not provided ongoing reassessments and monitoring to ensure the condition did not deteriorate and the patient remained safe. (Cross Reference A2407)

4. Ten of 23 sampled patients who were transferred from the ED to another acute care facility had missing or incomplete transfer documentation. (Cross Reference A2409)

Based on observation, interview and record review, the hospital failed to ensure the completion of an appropriate Medical Screening Exam (MSE) when:

1. Patient 1, who presented to the Emergency Department (ED) after an alleged suicide attempt was not assessed and triaged appropriately which resulted in her elopement and subsequent death.

2. Four of 22 sampled patients ( 8, 23, 26, 27) who presented to the ED with psychiatric signs or symptoms, including suicide attempts, suicidal ideation or an altered level of consciousness, were assigned a lower triage severity level than policy stipulated; and

Five of 22 sampled patients (2, 8, 23, 26, 27) who presented to the ED with complaints of depression or potential self-harm had an inappropriate suicide risk assessment for signs of depression or suicidal ideation.

3. There was no evidence of Medical Staff approval of labor and delivery nurses qualified to perform the MSE.

Findings:

1. Patient 1, a 40 year old, presented to the ED on 11/10/11 at 9:15 p.m. accompanied by her husband and son. From review of the facility's security videotape (covering the ED reception desk, lobby, and the outside ED entrance), and written security reports, the following timeline was established:

9:13 p.m. Patient 1's husband entered the ED lobby holding her arm. He leaned over the desk showing a staff member something he was holding in his hand. He assisted Patient 1 to an ED lobby chair.
9:16 p.m. Patient 1 was assisted to Triage Room B by her husband. Triage Nurse (TN1) instructed him to wait in the lobby with the son.
9:19 p.m. A female entered the lobby to get help with a gunshot wound victim (GSW) in a car outside ED entrance doors. TN1 left room to assist.
9:27 p.m. Patient 1 walked out through the ED entrance/exit doors. Immediately outside the doors she made a right turn and quickly disappeared from the camera screen. Patient 1's husband and a family member were conversing nearby but they did not appear to look in the direction Patient 1 traveled.
9:33 p.m. Patient 1's husband requested to join his wife in the triage room. This request was denied due to the emergent nature of the GSW in the ED treatment area.
9:36 p.m. Patient 1's husband responded when TN1 called his wife's name. He was told by TN1 that his wife left the triage room.
9:40 p.m. TN1 triaged another patient.
9:59 p.m. Patient 1's mother and mother-in-law asked TN1 if law enforcement had been called regarding Patient 1 being missing.
10:00 p.m. TN1 called the Stockton Police Department and notified the Charge Nurse (CN1) of Patient 1's elopement.
10:13 p.m. Jane Doe victim from a motor vehicle accident arrived in the ED in full cardiac arrest (Code Blue).
10:23 p.m. The Jane Doe Code Blue was discontinued and she was pronounced dead.
12:25 a.m. Jane Doe was identified as Patient 1.

Patient 1's medical record contained no triage assessment. A nursing note was written which documented "11/10/11 21:35 [9:35 p.m.] pt [patient] left while triage nurses were getting gsw victim out of car. . ."

In an interview with the Director of Emergency Services (DES) on 11/22/11 at 9 a.m., she stated Patient 1's husband had shown an empty prescription medication bottle to staff at the reception desk and told them Patient 1 had taken a large amount of pills, possibly Ambien [a medication prescribed to treat insomnia). The DES stated on the initial ED screening/admittance form Patient 1's husband noted "suicidal-overdose". The DES revealed Patient 1 was taken to Triage Room B at 9:16 p.m. by her husband who was told by TN1 to wait in the lobby. At 9:19 p.m., a GSW presented to the ED entrance and TN1 left Patient 1 in the triage room while she responded.

In an interview with the security guard (SG1) who was on duty in the lobby 11/10/11 from 2 p.m. until 10 p.m., she stated she was seated at the reception desk when Patient 1 was brought in by her husband and son at approximately 9:13 p.m. She stated Patient 1's husband leaned over the counter, "as if he didn't want his wife to see," and showed SG1 an empty pill bottle. He stated his wife had taken all of the pills that were in the bottle, which had been nearly full. SG1 stated the husband told her Patient 1 had "already passed out." SG1 stated Patient 1 was "hunched over in her own shell" and "was depressant". She stated she notified the triage nurse "right away". SG1 stated a short time later she was busy for some time dealing with the family and visitors of the GSW victim. SG1 stated no one asked her to watch Patient 1 in the triage room and she did not see her exit through the doors of the ED. SG1 revealed at approximately 9:35 p.m. she received a call from an ED staff member about a suspicious male walking around the ED parking lots. She dispatched another officer who identified the individual as Patient 1's husband who was searching for her. SG1 stated at that time she was not aware Patient 1 had eloped from the facility. SG1 stated two individuals [later identified as Patient 1's mother and mother-in-law] came to the reception desk and asked her if she had reported the missing patient to the police department. SG1 contacted TN1 who told her she had informed the police department at 10 p.m.

In an interview with TN1 on 11/23/11 at 10:45 a.m., she described the process for assessing a patient at risk for suicide. She stated she would ask the patient if they had actually attempted suicide or were "just trying to get attention." She stated further assessments for self-harm or risk for suicide would be "done in the back" [the ED rooms] by the bedside nurse. TN1 acknowledged she was Patient 1's nurse and stated she was informed by staff at the reception desk of the suspected attempted suicide. She stated she brought the patient back immediately to Triage Room B. TN1 stated she had just initiated the triage and was entering data into the computer when she left to attend to the GSW. TN1 stated she asked Patient 1 if she had ingested the pills or was she just seeking attention. TN1 stated the patient responded she was "in the middle," between trying to kill herself and getting attention from her husband. TN1 stated Patient 1's husband had told her there were 28 Ambien in the bottle. TN1 added "I always go with if the bottle is empty, the patient has taken all the pills". TN1 added "her speech, as far as I can remember, might have been starting to slur". TN1 stated she did not perform any additional physical, behavioral or suicidal assessments prior to leaving the room. TN1 acknowledged she did not notify CN1 of the need to provide constant attendance for the suicidal patient. TN1 further acknowledged she delayed informing security, the Charge Nurse and law enforcement of the elopement.

In a review of TN1's personnel file, there were multiple disciplinary actions:
a) On 7/21/11, TN1 received a second written warning regarding her refusal to follow the Charge Nurse's directions when she placed a patient in the waiting room rather than keep her in the triage room as instructed. This disciplinary action noted there had been "multiple complaints regarding disrespect, lack of courtesy and unprofessional behavior" in the past.
b) On 4/15/11, TN1 received a first written warning which cited "unprofessional and disruptive behavior in front of patients and staff".
c) On 5/6/10, TN1 received a final notice following an incident in which a patient left without being seen due to TN1's unprofessional behavior.
Additional disciplinary notices were given regarding professional behavior and communications in 2008 and 2009.

In an interview with CN1 on 11/23/11 at 8:15 a.m., she described a five level process for classifying patients acuity. She stated patients presenting with attempted suicide, would be assigned level 2 (Emergent). CN1 stated she was notified of Patient 1's elopement at approximately 11 p.m. when she was called to the reception desk to meet with Patient 1's family members who were "very upset" because they could not find Patient 1. CN1 stated "[TN1] told me the patient wasn't altered and answered questions appropriately". CN1 stated she asked TN1 if the patient had tried to hurt herself. TN1 responded a family member had told her [Patient 1] had done this before, "took the pills but really didn't". CN1 stated TN1 did not call her for assistance with Patient 1 while TN1 attended to the code blue GSW victim.

In an interview on 11/10/11 at 8 p.m., the second Triage Nurse (TN2) stated he did not have a patient at the time the GSW victim arrived in the ED. TN2 stated TN1 did not tell him about her suicidal patient with a suspected overdose. TN2 further revealed he had no knowledge of Patient 1's elopement until the middle of the night.

In interviews with the DES on 11/22/11 at 11:39 a.m. and 2:35 p.m., she described the standard practice for the assessment of patients presenting to the ED with a psychiatric complaint such as suicidal ideation or attempted suicide. The DES stated the patient would be asked by the triage nurse if he felt suicidal, or had thoughts of suicide, or was depressed. The DES stated that if the patient presented with a complaint of suicidal behaviors or suicidal ideations, the question was to be answered "yes" even if the patient was not thinking of self harm at that time. Answering "yes" prompted a mandatory evaluation called Suicide/Self-Harm Assessment Tool which was used to assign a risk level to the suicidal or depressed patient (high, moderate, or low risk of self-harm). The DES further stated a patient who actually attempted suicide was automatically assigned "one to one" continuous observation by a facility security guard or other qualified employee.

Review of a facility policy titled "Suicidal Patient Monitoring," reviewed 6/11 reflected that "all patients will be screened for suicidal ideation as part of the admission nursing process and risk factors for self-harm or harm to others will be identified". The policy further stipulated:

1. The Suicide/Self Harm Assessment Tool will be completed if initial screening indicates the patient to be at risk (which would be any patient presenting with suicidal behaviors or suicidal ideations),
2. Suicide Screenings and Suicide Risk Factor Assessments (tools defining the level of risk and interventions to be taken for each level) shall be documented in the computerized medical record and
3. Interventions according to level of suicide risk shall be documented (constant attendance provided, belongings removed, quiet environment, patient involvement in care plan).


2. Four of 22 sampled patients (8, 23, 26, 27) who presented to the ED with psychiatric complaints between 5/15/11 and 11/15/11 did not receive appropriate triage (which is the initiation of the MSE) when they were assigned a lower triage severity level than policy directed. In addition, triage screening documentation of four of 22 sampled patients (2, 8, 23, 26, 27) who presented with complaints of depression or actual/potential self-harm reflected no depression or suicidal ideation.

Review of the hospital policy titled "Triage Role/Responsibility," revised 2/11, reflected use of a five-level triage system including: Level 1 (Resuscitative), Level 2 (Emergent), Level 3 (Urgent), Level 4 (Semi-Urgent) and Level 5 (Minor). The policy further defined Level 2 conditions as those considered to be a potential threat to life, limb or function. The conditions for Level 2 included "acute psychiatric states".

In an interview with the DES on 12/12/11 at 11:47 a.m., she stated patients presenting with a psychiatric complaint were to be triaged as a Level 2 until further Suicide/Self Harm Assessments could be completed to determine the level of risk. The DES acknowledged the suicide risk assessments were not always completed.

In an interview with CN2 on 12/13/11 at 10:45 a.m., she stated she sometimes did triage for patients who were brought in by ambulance. CN2 stated patients with psychiatric complaints who had stable vital signs were always triaged as Level 3. CN2's understanding of the triage process was in contradiction with facility policy and the interview above.

a. Patient 2, a 39 year old, presented to the ED at 9:18 p.m. on 8/17/11 with depression and hearing voices telling him to kill himself. The triage nurse did no further suicide/self harm assessment to determine Patient 2's level of risk. Patient 2 was assigned a Level 2.

In an interview with RN2 on 12/13/11 at 8:30 a.m., he acknowledged he should have done further self harm/suicide assessments to determine Patient 2's level of risk.


b. Patient 8, a 33 year old, presented to the ED at 3:32 a.m. on 8/1/11 with depression and suicidal ideation. The triage nurse did no further assessment to determine why the patient no longer felt depressed or suicidal. Patient 8 was assigned a Level 4, instead of a Level 2 as defined by policy.


In an interview with RN3 on 12/13/11 at 9 a.m., she stated she was assigned to the ED from the Float Pool (a group of nurses trained to work in a variety of patient care settings). RN3 stated she had not received training or completed competency for working triage, but had been assigned to triage patients who came in by ambulance to the ED core. RN3 stated she assigned a Level 3 to Patient 9 because the patient was alert, oriented and cooperative.

In an interview with the DES on 12/14/11 at 11 a.m., she acknowledged RN3 had not received triage training and should not have been assigned to triage patients who arrived by ambulance.


c. Patient 23, a 22 year old, presented to the ED at 11:39 a.m. on 7/4/11 with "suicidal thoughts" and "panic". The triage nurse did no further suicide/self harm assessment to determine Patient 23's level of risk. Patient 23 was assigned a Level 3, instead of a Level 2 as defined by policy.


d. Patient 26, a 50 year old, presented to the ED on 6/13/11 at 1:28 p.m. with a "mental crisis," including anxiety and insomnia. She had a history of personality disorder, depression and substance abuse and was hallucinating according to her husband. The triage nurse did no further behavioral risk assessment. Patient 26 was assigned a Level 4, instead of a Level 2 as defined by policy.

e. Patient 27, a 25 year old, presented to the ED on 6/6/11 at 12:51 a.m. with suicidal ideation and depression. Patient 27 was assigned a Level 3 instead of a Level 2 per policy. While several safety measures being taken were documented at 8:27 a.m., the medical record did not indicate the presence of a safety attendant. At approximately 8:35 a.m., Patient 27 eloped from the ED and returned at an undocumented time accompanied by a pastor. After being seen by an inpatient psychiatric facility evaluator, she was placed on an involuntary hold at 10:30 a.m. The medical record showed no documentation of safety attendant presence. At 4:15 p.m., shortly after a discharge planning meeting including the patient, her mother, the hospital chaplain, security officers and nursing, Patient 27 was noted by the lobby security officer to have run out of the ED. Patient 27 was returned to the ED by her mother at an unknown time but shortly after ran out again. According to Patient 27's mother who again returned her, Patient 27 "took a handful of medications, mainly her Inderal [a medication used to treat high blood pressure or abnormal heart rhythms] " during her third elopement. The medical record does not state how the patient acquired the medication. After the third elopement, a friend remained at Patient 27's bedside and a security guard was placed outside the door to her room.

According to the facility's "Suicide/Self-Harm Screening Tool," revised 1/11 and completed at 12:25 p.m., 6/6/11, Patient 27 was at "high risk" for self-harm. Associated "suicide prevention interventions" for high-risk patients were to have included "1-1 supervision" and a "search of patient's belongings for potentially harmful objects."

3. In a tour of Labor and Delivery on 12/12/11 at 10 a.m., the Director of Maternal Child Services (DMCS) stated that approximately 40 nurses had completed training and determined competent to perform the MSE for patients presenting for evaluation of labor.

In review of the Medical Staff Rules and Regulations, Article 7, Emergency Services, Section 7.1 defined the categories of medical personnel who may perform medical screening examinations following standardized procedures, as applicable, approved by the Interdisciplinary Practice Committee (IDPC) and the Hospital. This included: "7.1.B.(2) Registered Nurses assigned to Labor and Delivery who have demonstrated competency to perform medical screening examinations for patients with pregnancy-related conditions under standardized procedures."

In an interview with the Manager of the Medical Staff Office (MMSO) on 12/13/11 at 10 a.m., she stated the Standardized Procedure (SP) for Labor Evaluation Exams by a Qualified RN had last been reviewed by the IDPC in August of 2010. The MMSO stated SP's were required to be reviewed annually.

In a concurrent interview with the Credentialing Coordinator (CC), she stated it was her responsibility to coordinate the IDPC meetings. The CC stated she was told by the DMCS in August that the SP was being revised. The SP was to be reviewed in December but the IDPC meeting was canceled. As of this date and time, the CC had not yet received the revised SP or the list of nurses who were deemed competent to perform the MSE.

In an interview with the DMCS on 12/13/11 at 11 a.m., she acknowledged the SP had not been submitted for a timely review by the IDPC.

Based on interviews and record review, the hospital failed to ensure a) nine of 30 sampled patients (Patients 2, 8, 9, 13, 22, 23, 24, 25, 26) who presented to the ED between 5/15/11 and 11/15/11 with a psychiatric complaint including suicidal attempt, suicidal ideations or an altered level of consciousness ) received ongoing assessments and monitoring to ensure appropriate interventions were being taken to stabilize the patient and provide for their safety.

These failures resulted in the potential for the undetected deterioration of the Emergent Medical Condition which would place patients at harm, including elopement.

Of the 30 sampled patients with a psychiatric complaint, there were 2 actual elopements (Patients 8, 26) and one potential elopement (Patient 2) from the facility during their stay in the ED.

Findings:

In review of a facility policy titled Assessment/Reassessment of Patients in the Emergency Department, revised 2/2011, there were instructions to perform a focused patient assessment every hour for Emergent (Level 2) patients, every two hours for Urgent (Level 3) patients and every four hours for Semi-Urgent (Level 4) patients.

This policy further stipulated the ongoing psychological assessment was to include cognitive and communication skills, response to teaching, response to hospitalization and coping skills. This assessment would include screening for suicide and, if suicidal, one to one observation for security. Re-assessments would include response to medication and treatment and any change (improvement or deterioration) in condition. Documentation requirements were defined as:
"a. Suicide Screenings and Suicide Risk Factor Assessments shall be kept as part of the permanent medical record..
b. Interventions, according to level of suicide risk, shall be documented in the patient's medical record.
c. Document any behavior or mood changes that may indicate the need for re-assessment of suicide risk and re-implement the Suicide Risk Factor Assessment Tool as needed, re-adjusting the interventions accordingly."

In review of a facility policy titled Suicidal Patient Monitoring, reviewed June 2011, there was stipulation "All patients presenting...will be screened for suicidal ideation as part of the admission process and risk factors will be identified. The Suicide/Self Harm Assessment Tool will be completed if initial screening indicates the patient is at risk." The policy further directed the nurse to use the Suicide/Self Harm Assessment Tool to re-assess the patient if the risk factors decreased or increased in order to determine the appropriate level of precautions.

In review of a form titled Suicide/Self Harm Assessment Tool, revised 10/04/11, there were descriptors to be scored when present. Patients with a 10 or higher score were assessed as high risk while patients with a score of 3-9 were moderate risk. Interventions were defined according to the patient's level of risk. The Assault and Violence Screening tool was similarly designed and patients with a score of 9 or higher were determined to be high risk.

In review of medical records, the following was noted:

a. Patient 2, a 39 year old, presented to the ED on 8/17/11 at 9:18 p.m. with complaints of mental problems, depression and hearing voices. The physician, in the initiation of the Medical Screening Exam (MSE) at 9:36 p.m., stated Patient 2 "was hearing voices telling him to kill himself ". There was no evidence any risk assessment for suicide/self harm or elopement was done for this patient. There was no evidence of any interventions taken to ensure Patient 2's safety and prevent further deterioration of the psychiatric crisis. From 9:18 p.m. until 7:43 a.m., there were no ongoing assessments or monitoring of Patient 2. On 8/18/11 at 7:46 a.m., Patient 2 told his nurse he heard voices telling him to "do bad things". The nurse did not initiate a suicide/self harm re-assessment which would include any behavioral changes or interventions initiated. Patient 2 was found in the parking lot by a nurse at 10:07 a.m. and was brought back in to the facility. Patient 2 was placed on a 5150 (a 72 hour involuntary hold) by the Behavioral Health Crisis Worker (BHCW) at 10:29 a.m. and transferred to an in-patient psychiatric facility on 8/18/11 at 12:41 p.m.

In an interview with RN2 on 12/13/11 at 8:30 a.m., he acknowledged he should have done a self harm/suicide risk assessment due to Patient 2's history of depression and schizophrenia as well as his presenting complaints.

In an interview with RN4 on 12/13/11 at 10:55 a.m., he acknowledged patients triaged as Level 2 would be assessed every hour. These assessments would include the patient's affect, any communications, comfort measures and response to any interventions taken. RN4 stated this would be documented in the drop down ED Rounding assessment tool and in narrative nursing notes. RN4 acknowledged he had not performed a suicide/self harm assessment and had not documented ED Rounding for Patient 2.


b. Patient 8, a 33 year old, was brought to the ED by law enforcement on 8/1/11 at 3:32 a.m. Patient 8's wife had called 911 as he was threatening to kill himself with a loaded gun. The Triage Nurse documented Patient 8 was depressed and had suicidal thoughts. There was no evidence of any self harm/suicidal risk assessment from triage at 3:32 a.m. until Patient 8 eloped at 5:55 a.m.

c. Patient 9, a 51 year old, arrived by ambulance to the ED on 8/5/11 at 11:10 a.m. Patient 9's family had called 911 as Patient 9 was intoxicated and had stated he wanted to die. Patient 9 had a history of depression and alcohol abuse and had been seen in the ED four times in the past month. The Suicide/Self Harm Assessment was completed at 1:31 p.m. with a score of 10, however the nurse documented Patient 9 as a moderate instead of high risk. At 3:49 p.m. Patient 9 informed the nurse "I want to kill myself". There was no evidence of a re-assessment for self harm or any interventions taken to ensure Patient 9's safety or prevent further deterioration of the psychiatric crisis. Patient 9 was placed on a 5150 hold by the BHCW at 4 p.m. as a danger to himself. Patient 9 was transferred to an in-patient psychiatric facility on 8/6/11 at 3:44 a.m.

In an interview with RN3 on 12/13/11 at 9 a.m., she stated she was assigned to the ED from the Float Pool (a group of nurses trained to work in a variety of patient care settings). RN3 stated she had no experience with the management of patients with a psychiatric crisis and was told by one of the nurses to do the Suicide/Self Harm Assessment. RN3 acknowledged Patient 9 should have been placed at high instead of moderate risk.

d. Patient 13, a 22 year old, presented to the ED on 8/25/11 at 10:12 a.m. with depression and "feels he wants to kill himself". There was no evidence of any self harm/suicidal risk assessment. Between 10:12 a.m. and 1:10 p.m., there was no evidence of ongoing behavioral assessments or documentation of interventions taken to ensure Patient 13's safety or prevent further deterioration. At 1:10 p.m., the nurse documented "pt attempting to leave on occasion" and "empty ambulance gurney went by and pt jumped up on the gurney". There was no evidence of a re-assessment for self harm or any interventions taken to ensure Patient 13's safety at that time. There was no evidence of ongoing behavioral assessments and monitoring. At 3:25 p.m., Patient 13 was placed on a 5150 hold by the BHCW as a danger to himself. Patient 13 was transferred to an in-patient psychiatric facility on 8/25/11 at 6:40 p.m.


e. Patient 22 presented to the ED on 7/7/11 at 4:58 p.m. with complaints of depression. At 7:42 p.m. the nurse documented "pt has thoughts of hurting self and possibly others but does not have a plan at this time". At 10:30 p.m., a form titled Assault and Violence Screening Tool was completed and indicated Patient 22 required high risk precautions. There was no evidence of any violence or assault precautions taken. Patient 22 was transferred to an in-patient psychiatric facility on 11/8/11 at 4:45 a.m.

In a review of Patient 22's medical record with the DSE on 12/14/11 at 7:30 a.m., she stated the self harm assessment should have been done at 7:42 p.m. when Patient 22 expressed suicidal ideations.

f. Patient 23, a 22 year old, presented to the ED on 7/4/11 at 11:39 a.m. with suicidal thoughts. Patient 23 had a history of depression. A Self Harm Assessment was done at 3:05 p.m. in which Patient 23 described frequent morbid thoughts and intermittent suicidal ideations. Intensified monitoring by the patient's mother began at 3:23 p.m. and at a later, undocumented time, a security guard took over monitoring; the mother resumed the monitoring at 4:12 p.m. Patient 23 was seen by the BHCW and placed on a 5150 at 8:48 p.m. as a danger to herself. There was no evidence of what interventions were taken to prevent Patient 23 from self harm. Patient 23 was transferred to an in-patient psychiatric facility at 9:58 p.m.

g. Patient 24, an 18 year old, presented to the ED on 5/29/11 at 8:51 p.m. after attempting to hang himself with a rope. Patient 24 was screened for high risk in the self harm/suicide assessments. At 2:34 p.m., the BHCW placed Patient 24 on a 5150 as a danger to herself. There was no evidence of hourly assessments to monitor Patient 24's behavior. Patient 24 was transferred to an in-patient psychiatric facility on 5/30/11 at 1:30 p.m.

h. Patient 25, a 16 year old male, was brought to the ED by law enforcement on 6/12/11 at 10:25 p.m. after threatening to harm himself and family members. Patient 25 was agitated and uncooperative. There was no evidence of ongoing assessments and monitoring from 8:01 a.m. until Patient 25 was transferred to an in-patient psychiatric facility at 12:15 p.m.

i. Patient 26, a 50 year old, presented to the ED on 6/13/11 at 1:28 p.m. with depression, anxiety and hallucinations. There was no evidence of any assessment for self harm or suicide. Patient 26 eloped from the ED at 11:32 p.m.

In an interview with the DES on 12/14/11 at 9:05 a.m. she stated the transition to the computerized medical record system had been challenging. The DSE acknowledged the ED staff was not familiar with all of the screens available to them and documentation, particularly for patients with a psychiatric emergency, had been inconsistent.

Based on interview and record review, the hospital failed to a) show evidence of required documentation and b) adhere to policy and procedure when the following information was missing or incomplete for 7 of 23 patients transferred to another healthcare facility from the Emergency Department (ED):

1. The reasons for transfer (2, 4, 5, 13,) ;
2. Indication the patient was stable or unstable for transfer (2, 4, 5, 13 );
3. Summary of the risks and benefits of transfer (2, 4, 5, 9, 13, 22);
4. Physician certification that the medical benefits outweighed the risks of the patient being transferred (2, 4, 5, 13, );
5. The patient's signature indicating understanding of the risks, benefits, and process for transfer (2, 4, 5, 13 ).
6. Evidence the receiving hospital accepted the patient and had appropriate space and personnel to care for the patient (2, 4, 5, 13);
7. Physician orders to be utilized during the transfer (2, 4, 5, 13);
8. Records sent with the patient (2, 4, 5, 6, 13);

Findings:

The hospital policy titled "Transfer of Acute Care Patient From Emergency Department To Another Healthcare Facility," dated 4/2001, revised 6/2008, was reviewed. Section III B. 2. stipulated "The transferring physician must determine whether the patient is 'medically fit' to transfer . . . The patient should be 'given a complete explanation of the need for the transfer, the alternatives to the transfer, risks and benefits to transfer and have executed a signed consent for transfer'." The policy further stipulated the physician is to complete the Patient Consent for Transfer, Physician's Certification, and Physician's Authorization of Transfer forms. Section D of the policy stipulated nursing was responsible for verifying the appropriate documents were completed and sent to the receiving facility.

The hospital forms which were to be used to provide required information for patient transfer were presented by the hospital and contained the following information:

1. Physician Authorization for Transfer: This form was used to document the receiving hospital's acceptance of the patient, acknowledgement of adequate space and staff for the patient; whether or not the patient was stable or not stabilized for transfer; mode of transfer; continued care orders; and records sent with the patient.

2. Consent for Patient Transfer: This form was used to document the patient had been informed of the right to a medical screening exam, the reasons for transfer, a summary of the risks and benefits of transfer, the physician's certification that benefits outweighed risks for transfer; and a place for the patient to sign indicating understanding of the process.

a. Patient 2, a 39 year old, presented to the ED on 8/17/11 at 9:18 p.m. with complaints of mental problems, hallucinations, suicidal ideation, and depression. Patient 2 was placed on a 5150 and transferred to an acute psychiatric hospital (APH) on 8/18/11 at 12:39 p.m. There was no evidence of a Physician's Authorization for Transfer or a Consent for Patient Transfer which would have included the receiving hospital had accepted the patient and had appropriate space and personnel for the patient; whether or not the patient was stable or not stabilized for transfer; continued care orders; records sent with the patient; the reason for and the summarized risks and benefits of transfer, the physician's certification that benefits outweighed risks for transfer; and the patient's signature indicating understanding of the risks, benefits, and process.


b. Patient 4, a 66 year old, presented to the ED on 8/21/11 at 9:44 p.m. after he attempted suicide. Patient 4 was placed on a 5150 and transferred to an APH on 8/22/11 at 6:20 a.m. There was no evidence of a Physician's Authorization for Transfer or a Consent for Patient Transfer which would have included the receiving hospital accepted the patient and had appropriate space and personnel for the patient; whether or not the patient was stable or not stabilized for transfer; continued care orders; records sent with the patient; the reasons for and the summarized risks and benefits of transfer, the physician's certification that benefits outweighed risks for transfer; and the patient's signature indicating understanding of the risks, benefits, and process.

c. Patient 5, a 24 year old, presented to the ED on 9/3/11 at 7 a.m. with a complaint of suicidal ideation. Patient 3 was placed on a 5150 and transferred to an APH on 9/3/11 at 5 p.m. There was no evidence of a Physician's Authorization for Transfer or a Consent for Patient Transfer which would have included the receiving hospital accepted the patient and had appropriate space and personnel for the patient; whether or not the patient was stable or not stabilized for transfer; continued care orders; records sent with the patient; the reasons for and the summarized risks and benefits of transfer, the physician's certification that benefits outweighed risks for transfer; and the patient's signature indicating understanding of the risks, benefits, and process.

d. Patient 6, a 43 year old, presented to the ED on 9/7/11 at 12:52 p.m. with complaints of suicidal ideation, nausea, and daily alcohol intake for the last 6 months. Patient 6 was transferred to an APH on 9/8/11 at 1:30 a.m. There was no documentation that Patient 6's medical records were sent with the patient at the time of transfer.

e. Patient 9, a 51 year, presented to the ED on 8/5/11 at 11:10 a.m. with complaints of depression and suicidal ideation. Patient 9 was placed on a 5150 and transferred to an APH on 8/5/11 at 1:09 p.m. There was no summary of the risks of transfer in Patient 9's record.

f. Patient 13, a 22 year, presented to the ED on 8/25/11 at 10:12 a.m. with complaints of depression and suicidal ideation. Patient 13 was placed on a 5150 and transferred to an APH on 8/25/11 at 4 p.m. There was no evidence of Physician's Authorization for Transfer or a Consent for Patient Transfer which would have included the receiving hospital accepted the patient and had appropriate space and personnel for the patient; whether or not the patient was stable or not stabilized for transfer; continued care orders; records sent with the patient; the reasons for and the summarized risks and benefits of transfer, the physician's certification that benefits outweighed risks for transfer; and the patient's signature indicating understanding of the risks, benefits, and process.


g. Patient 22, a 20 year old, presented to the ED on 7/7/11 at 4:58 p.m. with a complaint of depression and wanting help. Patient 22 had a history of suicidal thoughts and a recent suicide attempt. Patient 22 was placed on a 5150 and transferred to an APH on 7/8/11 at 3:45 a.m. There was no summary of the risks of transfer in Patient 22's record.

In an interview with the Chief Nurse Executive (CNE) on 12/12/11 at 4:15 p.m., she stated she was unaware that ED staff had been instructed that transfer forms were not necessary when transferring a patient to a psychiatric facility within the same corporation.

In an interview with RN1 on 12/13/11 at 10:20 a.m., she verified patient transfer forms included the Physician Authorization for Transfer and the Consent for Patient Transfer. She stated the completed forms were to be reviewed by the Nurse prior to transfer and were to be sent to the receiving hospital with the patient.