HospitalInspections.org

[The provider agrees,] in the case of a hospital as defined in 489.24 (b), to comply with 489.24.

Based on interview, record review and review of hospital policies and procedures, the hospital failed to implement their policies and procedures for transferring patients to another acute care facility in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to ensure patients receive safe transfer risks poor health care continuity, outcomes, injury, and death.

Findings included:

1. The hospital failed to obtain acceptance from the receiving facility,ensure physician-to-physician or nurse-to-nurse handoff or complete the required EMTALA documentation in the medical record of 2 of 4 patients (#1101, and 1110).

Cross-reference: Tag A-2409

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Based on interview, record review and review of hospital policies and procedures, the hospital failed to provide evidence that a) patients were informed of the risks and benefits of transfer if stabilization was not possible; b) the hospital ensured there was an accepting physician and hospital prior to transferring the patient; c) the hospital ensured patients were appropriately monitored during transpoort; and d) the hospital sent copies of all medical records pertaining to the patient's emergency care to the receiving facility when patients were transferred to another hospital, as demonstrated by 2 of 4 patients reviewed (Patient #1101, #1110).

Failure to transfer patients between acute care facilities without ensuring EMTALA requirements are met risks poor health outcomes, injury and death.

Findings included:

1. Review of the Samaritan Healthcare policy and procedure titled, "Interfacility Transfer/EMTALA Emergency Medical Treatment & Active Labor Act, 7230-E-14" PolicyStatID: 7594407 dated 3/25/2020 showed that all stable patients needing transfer to another acute care facility will be transferred only with a physician order and after acceptance is made by the receiving hospital physician. If non-emergencies, and with an order from the physician, a patient may be transferred by private vehicle. The EMTALA Memorandum of Transfer and copy of medical record must be sent to the receiving facility.

2. Review of the medical records for Patient #1101 showed the following:

a. Patient #1101 presented to the Samaritan Emergency Department (ED) on 11/05/20 with law enforcement complaining of sucideal ideation with a plan to slit her neck with a knife. Patient was evaluated, medically cleared and seen by the Grant Integrated Health Services Designated Crisis Responder (DCR). Patient refused to contract for safety and stated she did not know if she would be able to keep safe going forward. There is no evidence that the patient was placed on an involuntary hold. DCR note dated 11/06/20 at 6:43 PM, stated that DCR offered to call hospitals however the patient's father chose to take patient directly to Sacred Heart for Parent Initiated Treatment (PIT). DCR attempted to help coordinate placement but father declined the offer and stated he just wanted to drive her there.

b. Document review of DCR note 10:20 PM states telephone call to Sacred Heart spoke with Michelle (no title or department given) notifying her that patient and father were on their way.

c. Review of the discharge disposition showed, "Dad to drive patient to Sacred Heart".

d. Review of the patient's discharge instructions showed that the patient was to go directly to the Sacred Heart Emergency Department. Medical record review showed no evidence that the receiving hospital accepted the patient transfer, a physician-to-physician and nurse-to-nurse handoff occurred, or the EMTALA transfer forms were completed.

3. Review of the medical records for Patient #1110 showed the following:

a. Patient was brought to the Samaritan ED by private vehicle with her stepmother on 10/12/20 with a chief complaint of suicidal ideation with a plan to hang herself from her bunkbed. The patient received a medical screening exam and was cleared for assessment by the DCR. DCR assessment initially showed that the patient would be placed on an involuntary hold (ITA), but after contracting for safety and developing a plan for outpatient follow up, the patient was to be discharged home.

b. Provider notes stated that the patient was seen by the psychiatric intake team who are advising mom to drive her to Sacred Heart for evaluation as she was recently discharged from the hospital and is already exhibiting signs of needing to be readmitted. Provider notes also stated that the intake team and mom believe they can keep her safe and transport.

c. Discharge Instructions stated to proceed to Sacred Heart for evaluation at Children's to consider psychiatric intake.

d. Medical record review showed no evidence that the receiving hospital accepted the patient transfer, a physician-to-physician and nurse-to-nurse handoff occurred, or the EMTALA transfer forms were completed.

4. On 11/24/20 at 9:30 AM, Investigator #11 interviewed staff RN working in the ED (Staff #1101) who stated that once psychiatric patients are medically cleared, the Crisis Response Unit makes the decision where the patients go and obtains beds. If a bed cannot be found, the patient is held in the ED.

5. On 11/24/20 at 9:47 AM investigator #11 interviewed ED Director (staff #1102) who stated that when a patient needs to transfer to another facility for psychiatric treatment, the Designated Crisis Responder (DCR) "gets the bed." She also stated that she overheard a DCR contract for safety with a patient followed by instructions to go directly to another hospital upon discharge from Samaritan ED. The ED Director stated that she followed up with the DCR about this process and she was informed that the DCRs have done this for years but only with pediatric patients.