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Based on a review of medical records, interviews with staff and patients, and a review of the facility's policies, it was determined the facility failed to comply with 42.CFR 489.2, as a result one patient (P#1) out of 20 sampled was improperly transfered to another facility.

Cross refer to A-2409, as it relates to the facility's failure to provide P#1 with an appropriate transfer.

Based on a review of medical records, interviews, documentation records, Emergency Department Central Log, and a review of policies and procedures, it was determined the facility failed to provide a safe transfer for one patient, (P#1) of 25 patients. P#1 presented to the facility's Emergency Department (ED) with an emergency medical condition on 8/27/2021 but was not provided a safe transfer to a subsequent facility.

Findings:

A review of the facility's Emergency Department (ED) central log revealed that Patient (P), (P#1) was admitted to the facility's ED on 8/27/21 at 2:27 a.m., on a 1013 (involuntary detention due to probability of self-harm and inability to care for self) with the chief complaint of Suicidal thoughts (a person who expressed the desire to harm self).

A review of P#1's medical record documented P#1 presented to the facility and was triaged on 8/27/21 at 2:34 a.m., with suicidal thoughts. P#1 stated to her family that she attempted to strangle herself. P#1 reported on admission she took four Fioricets (a controlled pain medication used to treat tension headache) for headaches. P#1 presented to the Emergency Department (ED) with marks on her neck. Registered Nurse (RN), RN AA triaged P#1 at a level 2 (Acuity Level 2: A condition that indicated the patient was at risk and required immediate medical attention). A self-harm assessment performed by RN AA noted P #1 answered "yes" to questions related to recent depression, hopelessness, and thoughts of self-harm. Patient #1 recorded vital signs were: Blood Pressure:115/77, Heart Rate: 109, Oxygen Saturation: 96%, Temperature: 98.8. P #1 described her Pain Level as 10/10 (1 to 10 pain scale and 10 equals severe pain). P#1 was placed in a room at 2:44 a.m. Patient #1's past medical history included: prior suicidal attempts, active Depression, and Cancer (resolved).

Patient #1's past surgeries included a PEG Tube placement (a tube surgically placed in the abdomen through a small incision for medication and food administration) and partial Gastrectomy (removal of a portion of the stomach through surgery). The lab results revealed P#1's blood was positive for THC (Tetrahydrocannabinol, the pharmacological name for marijuana), Barbiturates (a class of sedative and sleep-inducing drugs), and Opiates (a class of medication used for pain relief). A late entry nursing progress note dated 8/27/21, 3:11 a.m. noted P#1 was placed on a 1013. The note confirmed P#1 attempted to strangle herself with a scarf. Redness was documented around P#1's throat. P#1 reported if, given the opportunity, she will attempt suicide again.

A nursing note on 8/27/21 at 4:50 a.m. documented a safety sweep of P#1's room was completed and that an order for protective custody was placed on P#1. On 8/27/21 at 5:45 a.m., a medical exam was documented. A nursing progress note dated 8/27/21 at 4:06 p.m. documented that P#1's information was faxed to the facility's local psych partner, who provided psychiatric consults. On 8/27/21 at 5:22 p.m., a nursing progress note documented the psychiatric partner called and stated P#1 was placed on the GCal's Board (a statewide system that lists patients in need of psychiatric placement so that a facility with a bed could accept the patient). P#1's status on the GCal's board was placed at status yellow due to a low potassium level disclosed in the laboratory results.

On 8/27/21 at 8:41 p.m., an Emergency Department note by Medical Doctor (MD) MD KK documented P#1 was medically cleared for transfer to a psych facility. Lab results collected at 8:56 p.m. documented P#1's potassium at 3.6MMOL/L (normal range 3.5-5.1 MMOL/L).

A note on 8/30/21 at 2:19 p.m. documented Ward Clerk (HH) spoke with a representative from a local psychiatric facility, and paperwork had been sent to an accepting doctor. Clerk HH called back for an update but did not receive an answer. On 8/31/21 at 4:36 p.m., P#1 was discharged into the care of a local deputy. On 8/31/21 at 5:00 p.m., a discharge order was written; Pt #1 was to be discharged to a mental or psychiatric facility per judge orders.

An Order to Apprehend dated 8/31/21 attention to any Peace Officer of said county noted, you are commanded to take the above-named individual (P#1) into to custody who can be found at the facility under investigation and deliver to the address of a crisis stabilization unit for an examination as prescribed by law.

An interview with Ward Clerk (HH) took place in the conference room on 9/14/2021 at 10:00 a.m. Clerk HH stated P#1 had been admitted to the Emergency Department (ED) for about 96 hours on a 1013. Clerk HH stated after being there for so long, she called the judge to help P#1 get out. Clerk HH said P#1 needed help but was not getting any by just lying down in the ED. Clerk HH stated after she called the judge, the judge did an Affidavit on P#1, and the sheriff came and took P#1 to the psych facility. Clerk HH said she spoke with a staff person (was not certain of the name) at the other facility to let her know P#1 was on her way. Clerk HH stated she had done that for a few patients before and indicated she was trying to get the patients to a place where they could get the help they needed. Clerk HH said P#1 had a feeding tube in place, but that was not a problem because P#1 ate normally and never vomited.

An interview with the Emergency Department Unit Coordinator (RN AA) took place in the hallway across from the administration area on 9/14/21 at 10:55 a.m. RN AA stated during P#1's medical record review, there was documented contact with the receiving facility. RN AA said they could not possibly transfer P#1 to a facility without a transfer order and proof that the facility had accepted the patient. RN AA could not locate any doctor's order for transfer or documentation from the other facility stating they accepted the patient. RN AA confirmed there was no proof that P#1 was transferred according to the facility's transfer procedures.

An interview with Compliance Officer (CO) II took place in the conference room on 9/14/2021 at 11:30 a.m. CO II stated when behavioral health patients were held in the Emergency Department waiting for a behavioral health bed; the staff sometimes utilized the court system to expedite patients' discharge. CO II stated behavioral health patients that needed an inpatient bed are placed on a waiting list or board that is statewide. CO II stated uninsured patients sometimes waited for a bed greater than 96 hours. CO II explained that a Probate Court Judge could sign an Affidavit to have a patient involuntarily committed. The county sheriff was responsible for transporting the patient to an inpatient facility. CO II stated the receiving hospital initially placed the patient on the board, but the ED nurses also reached out to different facilities to try and get P#1 an inpatient bed. CO II recalled that contact had been made with the facility prior to her transport.

During a phone interview with the receiving facility's Nurse Practitioner (NP) LL on 9/14/21 at 12:59 p.m., NP LL stated she had done admissions and intakes at the facility for four years. NP LL said the day before P #1 showed up at the facility, she reviewed her case on the board and denied accepting P#1 because the patient had a PEG tube (a surgical cut through the patient's belly for insertion of a tube for feeding and medication). NP LL said she denied P#1 for medical reasons as the patient was on continuous tube feedings, which required special care. NP LL further stated P #1 did not have any suicidal thoughts that prompted an admission. NP LL said their facility did not have the capabilities nor the capacities to accept a patient requiring special medical care. NP LL said the most advanced equipment they had was an ambu bag (a handheld device used to provide mechanical ventilation to patients who could not breathe properly). NP LL stated there was not a reason to contact a Judge to force the patient on them after they had denied the patient for medical reasons. NP LL stated that quite frequently that Facility #1 dumped patients on them. NP LL reiterated the receiving facility denied P#1 the day before law enforcement showed up with an incomplete Affidavit.

During a phone interview with the receiving facility's Clinical Director MM on 9/14/21 at 4:25 p.m., Director MM stated that P#1 was dropped off at their facility. Director MM stated her facility did not accept P#1 but rather, the patient was brought to the facility by a deputy with an Affidavit. Director MM stated the day before, her facility denied P#1 because she had a PEG tube in place, a medical condition that fell under the category and criteria of Exclusionary Medical Condition, a classification established by the Department of Behavioral Health and Developmental Disabilities (DBHDD). Director MM said their provider did a psychiatric evaluation on P#1 and concluded the patient was not a risk to herself or others. The receiving facility discharged the patient, discussed tube feeding needs with P#1's family, and recommended outpatient services.

An interview with the Emergency Department (ED) Nursing Director EE took place in the conference room on 9/15/21 at 10:25 a.m.; Director EE stated he had been the ED Director for two years. Director EE stated to transfer a patient, the facility notified the other facility. The receiving facility must consent to accept the patient and notify their physician to obtain a commitment to care for the patient. Director EE stated the facility filled out the forms that were to go with the patient. Director EE said if a patient was at the ED for a few days, the facility called the local judge, who also made phone calls to help find placement for the patient. Director EE stated the Ward Clerk usually made the call to the judge at the direction of an ED nurse or the ED physician, but the nurse or the physician could also make the call to the judge. Director EE said the facility discharged the patient with just the necessary paperwork.

An interview with Emergency Department (ED) Medical Director FF took place in the conference room on 9/15/21 at 11:15 a.m. Director FF explained the process to transfer a psychiatric patient from the Emergency Department to another facility was first to screen the patient before initiating a transfer. Director FF further explained the facility contacted a local psychiatric facility that evaluated psychiatric patients for them. This local facility was their partner that conducted teleconsultation for them. Next, they filled out Emergency Medical Treatment & Labor Act (EMTALA) cover forms to go with the patient. Director FF said they had to have acceptance from both the other facility and a physician at that facility before a transfer could occur. Director FF said acceptance was part of the process. Director FF said the local judge was an advocate for patients with mental health issues, and from time to time, the judge would get involved to help these patients get to the proper place and get the help they needed. Director FF said in the case of P#1; the judge made all the arrangements. Director FF said when the deputy was called to transfer a patient; the facility always gave the forms to the deputy to take with him.

An interview with P#1 took place in the Emergency Department (ED) on 9/15/21 at 12:05 p.m. P#1 stated she had been in the ED for a couple of days because she was not feeling well. P#1 stated she remembered she came because she was going to hurt herself. P#1 stated that during her last visit, the facility told her she would go to another facility, but they did not tell her where until the deputy arrived that day to take her.

Review of policy titled "Patient Transfers," policy number: none, effective date: 8/25/20, next review date: 8/25/22 revealed it was the policy of the facility to establish guidelines for the appropriate transfer of patients to another facility. The purpose of the policy was to ensure continuity of care and to promote communication among all members of the healthcare team and receiving facility. The policy applied to Patient Care Services, Emergency Medical Services, and the Medical Staff via the Clinical Policy Manual.

The policy defined "Transfer" as the movement (including the discharge) of an individual outside a hospital's facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the hospital; but did not include such a movement of an individual who had been declared dead or left the facility without the permission of any such person.

Further review of the policy revealed that the facility transferred a patient to another facility when:

2. The receiving facility had available space and qualified personnel for the treatment of the patient and had agreed to the transfer of the patient and to provide appropriate medical treatment.

3. The transferring facility sent to the receiving facility copies of medical records related to the medical condition of the patient that was available at the time of transfer.

4. The transfer was done by qualified personnel and transportation with effective equipment, as required, to include the use of necessary and medically appropriate life support measures during transfer.

The policy indicated procedures the facility followed when transferring a patient to another facility:

A. The transferring physician notified the receiving physician of the impending transfer.

B. Prior to the transfer, the physician wrote an order for transfer that included the receiving physician and facility.

C. The transferring physician completed the Patient's Request/Refusal/Consent form to include the risks, benefits, alternatives, and signature sections of the form.

D. The facility obtained consent for the transfer with the appropriate signatures of the patient or the person acting on the patient's behalf.

E. The facility nurse contacted the potential receiving facility to inquire room availability.

F. When the room became available, the nurse contacted the receiving facility and gave the patient report to the appropriate personnel. The nurse documented the name of the receiving personnel on the Patient's Request/Refusal/Consent form.