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Based on interview and record review, the hospital failed to arrange for an appropriate transfer for one patient (#9) with a psychiatric (relating to mental illness) emergency of 22 Emergency Department (ED) records reviewed from 02/19/24 through 08/19/24. Patient #9 was transferred without contacting or obtaining acceptance by an ED provider.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment, and transfers of individuals with an emergency medical condition [EMC])," dated 11/15/22, showed the following:
- The policy statement included the hospital's intent to comply with the EMTALA Anti-Dumping Act.
- If transfer to another facility is deemed necessary, the hospital will provide medical treatment within its capacity to minimize risk of the person's health.
- Before a patient is considered stable for transfer, the treating physician must determine the patient is expected to leave the hospital and be received at the receiving facility with no material deterioration in their medical condition and the receiving facility has the capability to manage the patient's condition and any reasonably foreseeable complication of that condition.
- In the case of a transfer, the receiving facility must be notified of the transfer and a physician (or physician representative) must agree to assume care of the patient upon arrival.
- When law enforcement (LE) officials request the hospital provide clearance for incarceration, a medical screening examination (MSE) must be performed by qualified medical personnel.

Review of the hospital's policy titled, "EMTALA Guidelines," revised 08/05/24, showed the following:
- The hospital may not transfer an individual who may be reasonably at risk to deteriorate from transfer or discharge. If the patient is at risk to deteriorate due to their medical condition, they are considered legally unstable.
- An unstable patient may be transferred if the hospital does not have capability to provide treatment and transfer is medically necessary.
- If a patient is transferred for medical necessity the provider must document that the risks and potential benefits of transfer were thoughtfully considered; the patient must consent, if able; the receiving hospital must accept the patient in advance and acceptance documented in the medical record; and transfer must occur in an appropriate medical transfer vehicle, unless the patient refuses and their refusal is documented in writing.
- An EMC is any condition that is a danger to the patient or could result in risk of dysfunction or impairment to any body part or organ, if not treated in the near future. EMCs include psychiatric disturbances such as depression (extreme sadness that doesn't go away) or the inability to comprehend danger or care for oneself.

Review of the hospital's policy titled, "Hospital Transfer Form Consolidated Omnibus Budget Reconciliation Act (COBRA)/EMTALA," dated 04/21/21, showed the hospital will comply with EMTALA as part of COBRA and provide the transfer form to staff to assist in compliance of the regulations. The policy outlined procedure which directed staff to print a transfer form for the provider to complete regarding a transfer, in addition to complete and print the nursing part of the transfer form.

Review of the hospital's policy titled "Transfer of Individuals with Unstabilized EMCs," dated 11/15/22, showed if a patient's EMC has not been stabilized prior to transfer, transfer may still be pursued if the individual requests transfer or the expected benefits outweigh the risks of transfer. If the provider certifies the benefits outweigh the risks, a qualified medical person may sign the certification of benefits versus risks only after a physician agrees with the transfer. Reasons for transfer must be included on the certification.

Review of the hospital's policy titled, "Emergency Psychiatric Care," dated 03/29/22, showed Scotland County Hospital does not have a psychiatric unit to provide psychiatric services. The hospital should provide safe management of patients requiring psychiatric services within its capabilities until the patient is safely transferred. Arrangements for transfer to an appropriate facility should be started as soon as possible according to each patient's situation and physician order.

Please see A2409 for further details.

Based on interview, policy review and record review, the hospital failed to arrange an appropriate transfer for one patient (#9) with a psychiatric (relating to mental illness) emergency of 22 Emergency Department (ED) records reviewed from 02/19/24 through 08/19/24. Patient #9 was transferred without contacting or obtaining acceptance of an ED provider.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment, and transfers of individuals with an emergency medical condition [EMC])," dated 11/15/22, showed the following:
- The policy statement included the hospital's intent to comply with the EMTALA Anti-Dumping Act.
- If transfer to another facility is deemed necessary, the hospital will provide medical treatment within its capacity to minimize risk of the person's health.
- Before a patient is considered stable for transfer, the treating physician must determine the patient is expected to leave the hospital and be received at the receiving facility with no material deterioration in their medical condition and the receiving facility has the capability to manage the patient's condition and any reasonably foreseeable complication of that condition.
- In the case of a transfer, the receiving facility must be notified of the transfer and a physician (or physician representative) must agree to assume care of the patient upon arrival.
- When law enforcement (LE) officials request the hospital provide clearance for incarceration, a medical screening examination (MSE) must be performed by qualified medical personnel.

Review of the hospital's policy titled, "EMTALA Guidelines," revised 08/05/24, showed the following:
- The hospital may not transfer an individual who may be reasonably at risk to deteriorate from transfer or discharge. If the patient is at risk to deteriorate due to their medical condition, they are considered legally unstable.
- An unstable patient may be transferred if the hospital does not have capability to provide treatment and transfer is medically necessary.
- If a patient is transferred for medical necessity the provider must document that the risks and potential benefits of transfer were thoughtfully considered; the patient must consent, if able; the receiving hospital must accept the patient in advance and acceptance documented in the medical record; and transfer must occur in an appropriate medical transfer vehicle, unless the patient refuses and their refusal is documented in writing.
- An EMC is any condition that is a danger to the patient or could result in risk of dysfunction or impairment to any body part or organ, if not treated in the near future. EMCs include psychiatric disturbances such as depression (extreme sadness that doesn't go away) or the inability to comprehend danger or care for oneself.

Review of the hospital's policy titled, "Hospital Transfer Form Consolidated Omnibus Budget Reconciliation Act (COBRA)/EMTALA," dated 04/21/21, showed the hospital will comply with EMTALA as part of COBRA and provide the transfer form to staff to assist in compliance of the regulations. The policy outlined procedure which directed staff to print a transfer form for the provider to complete regarding a transfer, in addition to complete and print the nursing part of the transfer form.

Review of the hospital's policy titled "Transfer of Individuals with Unstabilized EMCs," dated 11/15/22, showed if a patient's EMC has not been stabilized prior to transfer, transfer may still be pursued if the individual requests transfer or the expected benefits outweigh the risks of transfer. If the provider certifies the benefits outweigh the risks, a qualified medical person may sign the certification of benefits versus risks only after a physician agrees with the transfer. Reasons for transfer must be included on the certification.

Review of the hospital's policy titled, "Emergency Psychiatric Care," dated 03/29/22, showed Scotland County Hospital does not have a psychiatric unit to provide psychiatric services. The hospital should provide safe management of patients requiring psychiatric services within its capabilities until the patient is safely transferred. Arrangements for transfer to an appropriate facility should be started as soon as possible according to each patient's situation and physician order.

Review of Patient #9's Scotland County Hospital medical record, dated 05/06/24, showed the following:
- She was a 37-year-old female brought to the hospital by ambulance on 05/06/24 at 6:35 PM. Her reason for visit was listed as altered mental status (mental functioning ranging from slight confusion to coma) and police custody.
- A triage (process of determining the priority of a patient's treatment based on the severity of their condition) note documented the patient was brought to the ED by Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) and a LE officer. LE reported the patient was running around a cornfield with erratic behavior and told them "I think I'm the third coming of Jesus." The patient was in handcuffs.
- Staff K, ED Physician, documented Patient #9 was brought to the hospital handcuffed via EMS with a chief complaint of altered mental status. EMS reported that the patient became unresponsive once while lying in a cornfield, was given Narcan (a medication used to counter the effects of narcotic overdose) and had been awake and alert since Narcan was administered. Staff K documented "She is currently in handcuffs, but there are no charges against her." Patient #9 was having paranoid (excessive suspiciousness without adequate cause) delusions (false ideas about what is taking place or who one is) and cut the inside of her mouth with a knife attempting to remove a chip that she thought had been inserted in her jaw. Physical examination showed her head was atraumatic, eyes were dilated and a normal Ear, Nose, and Throat (ENT, subspeciality within medicine that deals with the surgical and medical management of conditions of the head and neck) examination. All other findings were normal except for her psychiatric state of agitated and manic (elevated or excited mood or behavior), swelling to the right side of her face and cuts inside her mouth. The examination of her face did not reveal drainage, infection, abscess (collection or pocket of thick fluid caused by an infection). She was treated with antibiotics and received medications to sedate and calm her agitation. Staff K documented the patient had been medically cleared with a urine drug screen (UDS, a test that analyzes urine for the presence of certain illegal drugs and prescription medications) positive for marijuana and benzodiazepines (a class of psychoactive drugs that act as tranquilizers and are commonly used to treat a range of conditions, including anxiety and insomnia); the patient had a prescription for benzodiazepines. Patient #9 received a psychiatric evaluation by a third party with recommendation for 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others). The involuntary detention (a legal process through which a person is hospitalized and treated for mental health disorders without their consent) paperwork was initiated with a plan to transport Patient #9 to Hospital B. Staff K documented the patient's disposition as "Transfer to a Psychiatric Hospital/Unit" and the clinical impression was schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly).
- A late entry nursing note on 05/07/24 at 9:38 AM, showed Facility C's LE officer accompanied Patient #9 in the ambulance and brought her into the ED with handcuffs on all four extremities. The officer uncuffed the patient, suggested that ED staff restrain the patient and obtain a 96-hour hold for psychiatric evaluation, and left the hospital. Facility C's LE officer told ED staff they could not hold the patient in jail until she had been medically evaluated. Facility D Sheriff Department was called requesting assistance with Patient #9.
- At 11:12 PM, Facility D Sheriff Department's LE officer arrived at the hospital to work on 96-hour hold paperwork.
- Nursing hospital transfer form was completed on 05/07/24 at 1:40 AM.
- The medical record contained a transfer form signed by Staff K on 05/07/24 at 1:40 AM, with the receiving hospital entered as Hospital B and the line for accepting physician left blank.
- Patient #9's medical record showed she was transferred by ambulance to a psychiatric hospital/unit on 05/07/24 at 3:37 AM.
- The medical record did not include documentation of discharge or discharge instructions, affidavits (a written statement confirmed by oath, for use as evidence in court) or 96-hour hold paperwork.

Review of the document titled, "Mark Twain Behavioral Health-Crisis Assessment," dated 05/06/24 at 9:40 PM through 05/07/24 at 1:14 AM, showed the following:
- The RN Crisis Outreach Clinician responded to Scotland County Hospital for evaluation of a patient in crisis (Patient #9). The evaluation was conducted in-person at the hospital.
- Patient #9 refused to answer the clinician's questions directly. The clinician spoke with the patient's parents who described her erratic behavior over the past few days. Patient #9 displayed a disorganized thought process and was unable to stay on topic. She had exhibited self-injurious behaviors and was deemed a potential danger to others. She had a history of a suicide (to cause one's own death) attempt in the past. She attempted to elope (make an intentional, unauthorized departure from a medical facility) from the ED twice and was restrained while in the ED.
- Patient #9's parents, LE, and the crisis outreach clinician completed affidavits in support of 96-hour hold involuntary detention for psychiatric assessment. The patient would be transported to Hospital B's Psychiatric Care Unit.

Review of the document titled, "Incident 24-214, Prehospital Care Report," showed the following:
- Staff N, Paramedic Facility E Ambulance District, documented Patient #9 was a 37-year-old female being transferred to Hospital B's Psychiatric Care Unit for evaluation. She was medically cleared and evaluated by a crisis outreach RN. A 96-hour hold and further psychiatric evaluation and treatment were recommended.
- Patient #9 was released from handcuffs and the LE officer with her was told that he did not need to accompany the patient in the ambulance, because "the patient was agitated by his presence."
- Medical records and 96-hour hold paperwork were received.
- Report was called to Hospital B prior to the ambulance's arrival, the patient was taken into Psychiatric Care Unit and report was giving to a RN.

Review of Patient #9's medical record from Hospital B, dated 05/07/24, showed the following:
- A section of the medical record contained consents and legal documents for application and approval of involuntary admission for psychiatric evaluation.
- Patient #9 was a 37-year-old female brought by ambulance to Hospital B's Psychiatric Care Unit from an outside hospital on a 96-hour hold. The outside hospital reported Patient #9 was running in the woods and tried to cut her own tooth out because she believed there was a tracking device implanted in the tooth. The outside hospital performed a urine drug screen which resulted positive for marijuana and benzodiazepines and gave Patient #9 an antibiotic due to facial trauma.
- Laboratory tests showed leukocytosis indicating possible infection, inflammation, or injury. The computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) examination showed air and inflammatory changes within a facial muscle. ENT was consulted and recommended intravenous (IV, in the vein) antibiotics. The patient was admitted to Hospital B's medical service and psychiatry was consulted.
- Patient #9 was transferred to Hospital B's Psychiatric Care Unit on 05/09/24 and discharged on 05/13/24.

Review of the documents submitted for 96 Hour Detention of Patient #9 showed a document titled, "Order for 96 Hour Detention, Evaluation and Treatment and Warrant," dated 05/07/24 was approved, signed, sealed by a judge from the Circuit Court of Scotland County, Missouri and Patient #9 was ordered taken by a LE officer to Hospital B for psychiatric detention, evaluation, and treatment.

During an interview on 08/21/24 at 1:45 PM, Staff K, ED Physician, stated that he was the physician who cared for Patient #9 during her ED visit on 05/06/24. He was under the impression that Patient #9 was brought to the hospital by Facility C Sheriff Department for medical clearance before they incarcerated her, but the LE officer was not specific as to what their needs were with regards to the patient. Staff K stated that he was informed by Facility D Sheriff Department's staff that Patient #9 was taken to Hospital B in an ambulance "on behalf" of LE and therefore it was not a hospital-to-hospital transfer. She had been medically cleared and LE was taking "custody" for transport. Therefore, he did not call Hospital B or formally arrange a transfer. He did, however, complete a transfer form without including a receiving physician and ensured the patient's medical records were sent with her.

During an interview on 08/21/24 at 11:05 AM, Staff H, RN, stated that she was the nurse in the ED when Patient #9 was brought to the hospital in an ambulance. The LE officer from Facility C Sheriff Department accompanied the patient in the ambulance and told the nurse Patient #9 was under arrest; but he was leaving the ED. The LE officer left the hospital and told ED staff they would prepare 96-hour hold paperwork. The patient was agitated, thrashing about and attempted to elope the ED; she called Facility D Sheriff Department to have a physical presence or "show of force" and enable hospital staff more freedom to perform healthcare tasks.

During a telephone interview on 08/23/24 at 7:00 AM, Staff J, RN, stated that he took over as the primary nurse for Patient #9 at about 6:45 AM on 05/07/24. The ED nurse usually made phone calls for psychiatric placement and the physician performed doctor-to-doctor discussions when a patient was transferred; but Patient #9 was different because the LE and the court initiated the 96-hour hold and transfer for psychiatric admission. The normal procedures for transferring a psychiatric patient were not completed with regards to Patient #9. It became a "pissing match" between the two sheriff departments. Staff J called Hospital B and talked with a nurse who was aware that the patient would be accompanied by LE and a doctor-to-doctor discussion had not occurred. The LE officer ended up not going with the patient.

During a telephone interview on 08/28/24 at 7:05 AM, Staff L, Deputy with Facility C Sheriff Department, stated that LE officers determined, for her own safety, she needed to be handcuffed until she could be evaluated by medical personnel. Staff L stated that he rode in the ambulance with Patient #9 at the request of the ambulance crew and she remained handcuffed because he was afraid she would injure herself or the ambulance crew. She was not under arrest. When the ambulance arrived, it appeared that the ED physician was upset they brought the patient to the hospital and told them "You can take her back now." He told the physician he had no reason to "take her", and "taking her" would be "kidnapping." At the request of Facility D Sheriff Department, he supplied an affidavit of the behaviors he witnessed with Patient #9.

During a telephone interview on 08/27/24 at 8:20 AM, Staff O, Deputy with Facility D Sheriff Department, stated that he thought they should have taken Patient #9 to the hospital in Quincy, Illinois, because they had a psychiatric unit. Their deputy did provide an affidavit in support of the patient's 96-hour hold for psychiatric evaluation. Staff O assisted with getting the involuntary detention paperwork completed and processed through the court system. Staff O was not aware that a LE officer did not accompany the patient to Hospital B with her court-approved, involuntary hold paperwork.

During a telephone interview on 08/28/24 at 1:30 PM, Staff M, Deputy with Facility C Sheriff Department, stated that on 05/06/24 at about 11:00 PM he went to Scotland County Hospital with the assignment to escort Patient #9 to Hospital B. The ambulance crew arrived and told Staff M he did not need to ride in the ambulance. Staff M gave the 96-hour hold paperwork to the ambulance crew. He was unaware the 96-hour hold paperwork specified that LE would take custody of and accompany Patient #9 to Hospital B.

During an interview on 08/30/24 at 7:00 AM, Staff N, Paramedic with Facility E Ambulance District, stated that he cared for Patient #9 during her transport from Scotland County Hospital to Hospital B on 03/07/24. When he arrived, Staff N's assessment of the patient's situation led him to believe that the presence of the LE officer made the patient more agitated; she appeared upset at being handcuffed and the LE officer being near her. Staff N told the LE officer that he did not need to go in the ambulance with Patient #9. He was aware that the patient's 96-hour hold was initiated by LE and the court and her transfer was not "on behalf" of the hospital. Patient #9 was transported directly to the Psychiatric Care Unit of Hospital B and report was given to an RN. Hospital B did not report any issue with receiving the patient.