HospitalInspections.org

Based on review of video footage, record review, policy review and staff interview, the hospital failed to ensure patients presenting to the emergency department receive a medical screening exam (A2406) and failed to ensure completion of the Transfer form utilized in the transfer of a patient from the hospital to another medical facility (A2409). The cumulative effect of this systemic practice resulted in the hospital's inability to ensure that all patients arriving at the emergency department would receive a medical screening exam and treatment as needed. The hospital registered an average of 2,028 patients per month in the preceding six months prior to the survey.

Based on review of video footage, record review and staff interview the hospital failed to ensure one (Patient #21) of twenty one sampled records received a medical screening exam. This has the potential to affect all patients presenting to the 18-bed emergency department. The hospital registered an average of 2,028 patients per month in the preceding six months prior to the survey.

Findings include:

Review of hospital policy, "6710.037 revised date: 4/03/17" was reviewed on 9/19/19. The purpose of the policy is to determine the nature and severity of the patient's presenting compliant in order to determine the urgency in which the patients will be seen by the physician for the medical screening exam (MSE) and treatment. Neither the initial MSE nor any needed stabilization treatment may be delayed by inquiries about services, payment or insurance status. Any patient presenting to the ED seeking emergency treatment for an illness or injury will be seen by a Health Care provider who will assess their condition...at number 18 Registration considerations: b. Process does not "unduly discourage" the individual from seeking further evaluation and treatment.

On 9/18/19 at 9:05 AM a video supported by transcript of the communication was reviewed. The video revealed a female accompanied by two Summit County Metro Park Rangers at the entrance to the facility's emergency department. The female does not come to the triage window. Park Ranger #1 requests a "pink slip" from ED triage nurse (Staff E-1). Staff E-1 reports, "yeah that's fine we just don't have psychiatric here." The video continues with the female declining to answer questions of Staff E-1 and the Park Rangers. The female verbalized, "I don't need to be pink slipped."

The facility emergency department charge nurse (Staff E-2) came to the triage area and reported to the Park Rangers, "we don't have psychiatric services here." The Park Rangers left the facility in their vehicle with the female seated in the front passenger seat.

Summit County Metro Park Rangers then brought Patient #21 to Hospital B's emergency department for evaluation per the medical record dated 09/03/19 at 1:21 AM. A pink slip was completed and the patient received a medical screening exam and was evaluated by psychiatry.


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Based on medical record review, policy review and staff interview the facility failed to ensure the completion of the Transfer form utilized in the transfer from the hospital to another medical facility for further care. Twenty-one medical records were reviewed during the survey. This affected ten of ten (Patient #'s 1, 7, 8, 9, 12, 13, 15a, 15b, 18 and 20) medical records reviewed of transferred patients. The hospital transferred an average of 42 patients per month in the preceding six months prior to the survey.

Findings include:

Review of hospital policy, "6710.036 revised date: 4/03/17" was reviewed on 9/19/19. The purpose of the policy is to provide guidelines for completion of the Transfer Report for patients being transferred to another medical facility. Bullet point two under "Please prepare the following packet of information to accompany the patient:" reads, "Copy of the completed (signed and labeled) transfer sheet."

Patient #1 came to the hospital emergency room on 9/18/19 at 7:35 AM with a chief complaint of "anxiety/situation crisis". Patient #1 was seen by the physician at 7:46 AM and received medical stabilizing treatment until transfer to a psychiatric facility at 12:50 PM. The treating physician certified the patient for transfer to a psychiatric facility on 9/18/19 at 11:15 AM. The transfer form is not complete as it lacks the initials of the person (from the transferring hospital) obtaining acceptance from the receiving institution, and the discussion of the benefits of transfer.

Patient #7 came to the hospital emergency room on 7/27/19 at 10:00 AM with a chief complaint of suicidal. Patient #7 was seen by the physician at 11:24 AM and received medical stabilizing treatment until transfer to a psychiatric facility at 4:46 PM. The transfer form is not complete as the treating physician did not sign the form certifying the patient for transfer.

Patient #8 came to the hospital emergency room on 7/26/19 at 12:24 PM with a chief complaint of suicidal. Patient #8 was seen by the physician at 2:13 PM and received medical stabilizing treatment until transfer to a psychiatric facility at 8:00 PM. The treating physician certified the patient for transfer to a psychiatric facility at 4:56 PM. The transfer form is not complete as it lacks the initials of the person (from the transferring hospital) obtaining acceptance from the receiving institution.

Patient #9 came to the hospital emergency room on 6/14/19 at 9:16 PM with a chief complaint of alcohol intoxication. Patient #9 was seen by the physician at 9:26 PM and received stabilizing treatment until transfer to a psychiatric facility at 8:41 AM on 6/15/19. The transfer form is not complete as it lacks the name of the accepting physician, the initials of the person (from the transferring hospital) obtaining acceptance from the receiving institution and the patient's condition at the time of transfer. In addition, Patient #9 was not transferred with his/her CT results.

Patient #12 came to the hospital emergency room on 8/28/19 at 10:30 PM with a chief complaint of weakness. Patient #12 was seen by the physician at 10:36 PM and received stabilizing treatment until transfer to an acute care facility at 1:45 AM on 8/29/19. The transfer form is not complete as it lacks the date and time of the patient's signature and what the patient's signature was consenting to; consent or refusal to transfer. In addition, Patient #12 was not stabilized on antibiotics prior to transfer.

Patient #13 came to the hospital emergency room on 8/28/19 at 7:29 PM with a chief complaint of alcohol intoxication. Patient #13 was seen by the physician at 7:38 PM and received stabilizing treatment until transfer to a psychiatric facility at 2:25 PM on 8/29/19. The transfer form is not complete as it lacks the initials of the person (from the transferring hospital) obtaining acceptance from the receiving institution and the time of the physician's signature on 8/29/19.

Patient #15a came to the hospital emergency room on 8/23/19 at 7:41 PM with a chief complaint of imminent birth. Patient #15a was seen by the physician at 7:39 PM and delivered a live birth at 9:13 PM. Patient #15a was transferred to an acute care facility at 9:51 PM on 8/23/19. The transfer form is not complete as it lacks the name of the receiving institution, the name of the accepting physician and the initials of the person (from the transferring hospital) obtaining acceptance from the receiving institution, the date and time of the patient's signature and no witness to the patient's signature.

Patient #15b was born in the hospital emergency room on 8/23/19 at 9:13 PM. Patient #15b was seen by the physician at 9:13 PM and received stabilizing treatment until transfer to an acute care facility on 8/23/19 at 9:51 PM. The transfer form is not complete as it lacks the name of the receiving institution, the initials of the person (from the transferring hospital) obtaining acceptance from the receiving institution, the patient's representative's signature and no witness to the patient's signature.

Patient #18 came to the hospital emergency room on 5/04/19 at 8:40 AM with a chief complaint of bizarre behavior/paranoid. Patient #18 was seen by the physician at 9:03 AM and received stabilizing treatment until transfer to a psychiatric facility at 2:21 PM. The transfer form is not complete as it lacks the name of the accepting physician, the initials of the person (from the transferring hospital) obtaining acceptance from the receiving institution and the risks of transfer.

Patient #20 came to the hospital emergency room on 4/21/19 at 10:25 AM with a chief complaint of depressed, PTSD and a history of rape. Patient #20 was seen by the physician at 10:43 AM and received stabilizing treatment until transfer to a psychiatric facility at 3:45 PM. The transfer form is not complete as it lacks the initials of the person (from the transferring hospital) obtaining acceptance from the receiving institution and the benefits of transfer.

These findings were confirmed with Staff A on 9/19/19 at 9:20 AM.