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Based on medical record review, document review, and staff interview the critical access hospital (CAH) failed to comply with their provider agreement to arrange an appropriate transfer. The CAH failed to ensure the receiving hospital had available space, qualified personnel, and agreed to accept the transfer for 1 out of 20 records ( patient #1) selected for review. The ED treated approximately 1,007 patients in the six-month period and transferred approximately 48 patients in the same six months to another healthcare facility.


Failure to arrange an appropriate transfer of a patient with an unstable emergency medical condition placed the patient at risk for an unsafe transfer and lack of subsequent stabilizing treatment that could potentially lead to further complications or death.


Findings include:


- The hospital's policy "EMTALA Transfer Policy" reviewed on 10/12/15 at 11:00am directed, "...It is the policy of the hospital to comply with all applicable laws and regulations relating to the provision of emergency services and transfer of patients, including requirements as defined in the Emergency Medical Treatment and Active Labor Act (EMTALA) ...An Emergency Medical Condition (EMC): is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe chest pain, psychiatric disturbances and/or symptoms of drug abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual in serious jeopardy, b. Serious impairment to bodily functions, c. Serious dysfunction of any bodily organ or part ...With respect to psychiatric conditions; a. Patient is assessed to have a psychiatric condition for which inpatient psychiatric care is medically indicated ...Stable for discharge; for the purpose of discharging a patient with psychiatric conditions, the patient is considered to be stable for discharge when he/she is no longer considered to be a threat to himself/herself or to others ...Stable for transfer; In the case of a patient who is suffering from psychiatric conditions, the patient is considered to be stable for transfer when he/she is protected and prevented from injuring himself/herself or others ...The receiving facility must have a) available space, b) qualified personnel for the treatment of the individual, c) agree to accept transfer of the patient and to provide appropriate medical treatment ...The referring physician must contact a physician at the receiving hospital who is authorized to admit/accept patients to describe the patient ' s condition, care rendered and to obtain consultative advice about stabilization and transport. The admitting physician at the receiving hospital must have accepted the patient and confirmed that appropriate resources are available at the receiving hospital before transport begins ...a designated hospital employee shall obtain approval of the receiving hospital facility before the transfer of any individual and shall make arrangements for the patient transfer with the receiving hospital ...The physician must outline the risks and benefits for transfer with the patient or legal surrogate prior to transfer. A copy of the certificate of transfer must accompany the patient. The certificate of transfer is to be signed by the physician ...All patients transferred from the hospital to go directly to another health care facility shall be treated as a "transfer" under this policy ...The decision to transfer is the responsibility of the attending physician ...The transferring physician will identify and contact an appropriate accepting physician to consult and confirm acceptance of the patient transfer. Bed and resource availability at the receiving facility will be considered in this acceptance. The transferring physician will be responsible to determine the equipment and staff needs for the transferring patient. The transferring physician will be responsible to inform the patient and his/her surrogates of the risk and benefits of the proposed transfer. The transferring physician will be responsible to complete a certificate of transfer ..."

- The hospital's policy "Treatment and Referral of Emotionally Ill or Chemically Dependent Patients " reviewed on 10/14/15 at 2:10pm directed, ...Transfer of the patient to a treatment facility shall be arranged in accordance with all applicable state and federal laws governing these patients and facilitated by the assigned mental health practitioner staff of the Mental Health Center of East Central Kansas when appropriate ... "

- Patient # 1's medical record reviewed on 10/12/15 revealed patient #1 presented to the emergency department (ED) on 9/24/15 at 11:55am with a complaint of chest pain and suicidal ideation (thoughts). Patient #1 received a medical screening exam and psychological examination. ED Physician staff B contacted Hospital BB, Hospital CC and Hospital AA for a transfer request. All Hospitals declined the request due to the patient's cardiac condition and lack of available beds. Staff B admitted patient #1 to the clinical decisions unit (CDU) in observation status on 9/24/15 at 9:16pm. Physician staff C ordered suicide precautions at level II and III (15-30 minute checks) that continued until the patient was discharged. Registered Nurse staff E received instructions from mental health staff D to discharge the patient and the mental health center (MHC) would provide transportation to Hospital AA for treatment of the patient's psychiatric condition. The CAH discharged patient # 1 with an unstable emergency medical condition on 9/25/15 at 4:48 PM and the attendant from the MHC transported the patient to hospital AA's ED in an unsecured vehicle.

See further evidence at 2409

Based on medical record review, document review, and staff interview the critical access hospital (CAH) failed to arrange an appropriate transfer for one patient (patient # 1) with an unstable emergency medical condition (EMC) out of 20 records selected for review. The Emergency Department (ED) treated approximately 1,007 patients in the six-month period and transferred approximately 48 patients in the same six months to another healthcare facility.


Failure to arrange an appropriate transfer of a patient with an unstable emergency medical condition placed the patient at risk for an unsafe transfer and lack of subsequent stabilizing treatment that could potentially lead to further complications or death.


Findings include:

- Patient #1's medical record reviewed on 10/12/15 revealed he presented to the emergency department (ED) on 9/24/15 at 11:55am with a complaint of chest pain and suicidal ideation (thoughts). Patient #1 stated his plan to commit suicide was by jumping in front of a car or off a bridge. Psychological evaluation was ordered and conducted by mental health staff D. Staff D concluded the patient met criteria for inpatient psychiatric treatment. ED Physician staff B contacted Hospital BB, Hospital CC and Hospital AA for a transfer request. All the contacted hospitals declined the request due to the patient's cardiac condition and lack of available beds. Staff B placed patient #1 on the clinical decisions unit (CDU) in observation status on 9/24/15 at 9:16pm with physician staff C assuming care. Physician staff C ordered suicide precautions at level II and III (15-30 minute checks) that continued until the patient was discharged. Registered Nurse staff E received instructions from mental health staff D to discharge the patient and the mental health center (MHC) would provide transportation to Hospital AA for treatment of the patient's unstable psychiatric emergency. The CAH dischared patient #1 on 9/25/15 at 4:48pm when the mental health attendant from the MHC arrived to transport patient #1 to Hospital AA's emergency department in an unsecured vehicle.

ED Registered Nurse (RN) Staff N interviewed on 10/13/15 at 9:30am acknowledged they provided care for Patient #1 on 9/24/15 and indicated Patient #1 reported suicidal thoughts while in the ED with multiple suicidal plans. Staff N indicated Patient #1 had an emergency medical condition.

CDU Registered Nurse staff E interviewed on 10/13/15 at 9:50am indicated patient #1 presented to the emergency department and was placed in observation in the CDU. Staff E stated they called Mental Health Staff D and received instruction that the MHC's attendant driver would be at the CAH to pick up patient #1 and transport them to Hospital AA with admission through the ED as a walk-in patient. Staff E called ED Physician Staff C to inform them of the communication with mental health staff D and received a telephone order for patient #1's discharge. Staff E acknowledged it was unusual to discharge a patient without filling out the proper COBRA (transfer papers indicating possible risks and benefits, available space and physician acceptance of the transfer) forms. Staff E acknowledged it was very rare for a patient to be discharged from CDU then go directly to an ED at another facility without it being a transfer. Staff E revealed the patient had not received reevaluation by mental health staff D prior to discharge.

Mental health attendant Staff G interviewed on 10/13/15 at 3:00pm indicated that they received instruction from MHC to pick up a patient at the CAH on 9/25/15. Mental health attendant Staff G arrived at hospital AA where the ED lacked knowledge of a patient coming to their facility and in fact had advised the CAH they did not have any beds available the day before when the CAH requested to transfer the patient to Hospital AA. Mental health attendant staff G reported the nurse at Hospital AA showed him on the computer screen the patients name and no bed available.

Group interview on 10/12/15 at 12:35pm with the CAH staff members: Administrative staff H, Administrative staff I, Administrative staff J, Administrative staff K, and Administrative staff L, indicated they were aware of a potential EMTALA violation. The CAH's investigation indicated physician staff A treated patient #1 in the ED on 9/24/15 with chest pain and suicidal ideations. The CAH needed to rule out cardiac issues and physician staff A contacted Hospital AA and Hospital CC for the psychiatric issues. The CAH placed Patient #1 in observation status and physician staff C assumed care. Mental Health staff D screened Patient #1 in the ED on 9/24/15 and Patient #1 met inpatient criteria for admission to a psychiatric hospital. Staff D worked on transfer to a psychiatric hospital and there were no beds available. About 4:00 to 5:00pm on 9/25/15 Registered Nurse (RN) Staff E called the Mental Health Provider Staff D to get the plan. Staff D advised the nurse to discharge patient #1 and the MHC would arrange transport to Hospital AA where the patient would walk-in to the emergency department. The RN Staff E was uneasy about not making transfer arrangements. The RN Staff E received instruction from Mental Health Provider staff D that there was no need to fill out COBRA (transfer papers) forms since the patient would be a discharge not a transfer. After the CAH became aware of the potential EMTALA, we called the Mental Health Center and the individual that facilitated the transfer (staff D) no longer works for the Mental Health Center. Hospital AA indicated patient #1arrived in a locked van when in fact mental health staff M confirmed that patient #1's transportation was provided by the Mental Health Center vehicle. Mental health Professionals are not employees of the CAH but are credentialed in the CAH as allied health professionals. We do not have psychiatric capabilities at our CAH. Normally with psychiatric patients, we clear them medically and consult with the Mental Health Center with psychiatric issues. The MHC identify needs; manage process of locating beds and transportation. The CAH's assumption was that mental health evaluator staff D was in contact with Hospital AA. Administrative staff indicated they rely on the Mental Health Provider and their interaction with staff. We needed to ensure proper transfer, should have filled out the COBRA forms, ensured the patient was stable, and verified by documentation.

Administrative staff I indicated they currently do not have any documentation if the patient was stable or not. The physician discharged the patient based on information provided by the Mental Health Provider. The physician trusted the Mental Health evaluator to make their decisions. Our opinion was we did not complete proper transfer paperwork. The staff RN could have gone up the chain of command if she had concerns about the discharge/transfer to Hospital AA. The CAH currently does not require contracted staff to take EMTALA training.

Administrative staff H confirmed the patient had a psychiatric emergency medical condition and that is what triggered the mental health evaluation.

The Mental Health Supervisor acknowledged there should have been documentation from Mental Health Staff D. All conversations with mental health staff or providers occurred over the telephone.

The CAH ' s Emergency department Physician staff B, interviewed on 10/13/15 at 1:15pm indicated that they decided to place the patient on observation status in the CDU to rule out acute cardiac issues and acquire psychiatric hospital placement. Physician staff B revealed that mental health staff D continued to assist in facilitating transfer options for patient #1. Physician staff B confirmed that this patient had an emergency medical condition while in the emergency department.

Mental Health Staff D interviewed on 10/13/15 at 9:00am confirmed they assessed patient #1 who had told the nurse that they wanted to commit suicide. Mental Health Staff D reported they called area psychiatric hospitals and they all wanted patient # 1's cardiac concerns cleared before accepting a transfer. Mental Health Staff D indicated the patient transferred to the CDU for observation. Mental Health Staff D acknowledged that they did not reevaluate patient #1 prior to discharge and did not feel like they needed to. Staff D also did not speak directly to the physician Staff C about the discharge plan. Mental Health Staff D confirmed that suicidal ideation is an emergency medical condition and they had never received EMTALA training.

The CAH's Physician staff C interviewed on 10/13/15 at 11:00am revealed they assumed care once the patient #1's status changed to observation and arrived on the CDU on 9/24/15. Physician staff C revealed they evaluated patient #1 who reported no suicidal thoughts or hallucinations and was very lucid, but they had failed to document these findings in the medical record. Physician staff C indicated a mental health professional from MHC assists patients with psychiatric conditions and they usually leave a plan in the patient's chart without directly communicating with the physician. Physician staff C acknowledged that they usually follow their plan and that they rely "heavily" on their recommendation. Staff C indicated they felt the patient could be discharged to the mental health plan, however staff C revealed they did not read the assessment completed by Mental Health Staff D from MHC the previous day in the emergency department and was unaware a reassessment had not been completed. Physician staff C indicated they assumed patient #1 was going to seek further treatment and was unaware where or how they would be getting there. Physician staff C stated their obligation ends when the patient discharges to the community.

Mental health Staff M interviewed 10/13/15 at 3:30pm confirmed a psychological reevaluation is completed "most of the time " before a mental health professional advises discharge and typically a phone call to the nurse would not be appropriate.

Registered Nurse staff O, Director of CDU, interviewed on 10/14/15 at 9:30am indicated Registered Nurse staff E, communicated that they were not comfortable with patient #1 being discharged to go home and felt the COBRA paperwork should have been completed. Staff O confirmed Staff E should have sought guidance by following their chain of command and speaking with the CNO or administration. Staff O revealed the facility typically does not know where a discharged patient is going, but if we do then we have an obligation to communicate with the receiving facility. Staff O confirmed the observation unit is an extension of the emergency department and those patients are not inpatients. I expect the CDU/Inpatient physician to read any evaluations including a Mental Screening evaluation and any other test results concerning their patient on observation. Staff O indicated their obligation to the patient ends when the receiving facility accepts the patient, but the patient must be stable, have proper documentation completed and the receiving facility must have an available bed. Staff O confirmed a patient with suicidal ideation and a plan would be an emergency medical condition.

Chief Quality Office Staff I interviewed on 10/14/15 at 2:10pm indicated the hospital failed to have written policies directing Mental Health Professionals on their requirement to document interaction with patients in the medical record. Staff I indicated they failed to have policies, communication, or training provided to Mental Health Professionals with expectations for communication to hospital staff. Staff I indicated the training included one Mental Health Professional shadowing another Mental Health Professional. Staff I indicated they expect a patient to have a reevaluation by a physician prior to discharge.