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Based on document review and staff interview, the emergency department (ED) staff failed to follow the critical access hospital ' s (CAH ' s) policies and did not provide one patient (Patient # 1) with further evaluation and medical treatment within its capacity to minimize the risks prior to transfer. The CAH also failed to develop a policy to protect staff from adverse action if they refused to authorize a transfer of an individual that had not been stabilized, or if any staff reported a violation of the Emergency Medical Treatment and Labor Act (EMTALA). Thirty medical records were selected for review from 8/1/11 to 2/8/12. The CAH administrative staff identified an average of 23 patients transferred from the ED to another hospital per month.

Failure to follow policies and procedures for restricting transfer of an individual until stabilized within the CAH ' s capacity, or obtaining physician certification that the benefits of transfer outweighed the risks and that mode of transport was appropriate, could place the individual at risk for deterioration or death during transfer. And failure to develop a whistleblower policy could place CAH staff at risk for retaliation if they refused to authorize the transfer, or reported a violation of EMTALA.

Findings include:

1. Review of Patient #1's ED Medical Record on 2/8/12 at 1:30 PM, revealed the following:

Emergency Medical Services staff responded to a 911 call at Patient #1's home on 1/20/12 at 11:28 AM. Documentation revealed Patient # 1 confirmed ingestion of pills to harm self, was agitated and yelling, did not want to go to the hospital, and stated "I don't care if I die." Before transport to the hospital, a law enforcement officer witnessed Patient #1 ingest a hand full of additional pills.

Patient #1 arrived in the ED at 12:25 PM with an emergency medical condition, and ED registered nurse (RN) A documented in the "INITIAL ASSESSMENT" Patient #1 admitted to "taking an overdose" of a prescribed medication Topamax and that the patient knew seizures were a side effect of too much Topamax. Physician's Assistant (PA) B examined Patient #1 and ordered laboratory tests, including a urine drug screen. The medical record did not contain evience that PA B directly consulted with poison control or thoroughly evalulated the patient's ingestion of Topamax with other pills.

At 1:51 PM PA B filed an application with the county court to involuntarily commit Patient #1 to a hospital for treatment of the Topamax drug overdose. At 3:05 PM, RN A filed an affidavit to support PA B's application to involuntarily commit Patient #1 to a hospital for treatment of the drug overdose. The medical record did not contain evidence that the CAH stabilized Patient # 1's emergency within its capabilities prior to arranging a transfer.

At 2:24 PM, laboratory staff completed testing Patient #1's urine, and documented the presence of Tylenol. The medical record did not contain evidence that PA B obtained a blood test to determine whether Patient # 1 had a toxic level of Tylenol in the blood.

At 2:50 PM, the ED nurse documented that Physician H came to the ED and tried to talk with Patient # 1 but the patient ran out of the ED and law enforcement were called for assistance.

At 3:05 PM, the ED nurse documented that law enforcement returned Patient # 1 to the ED and stayed at the bedside until the County and local Magistrate arranged a transfer to Hospital A.

At 4:25 PM, Sheriff's Deputy C arrived to transport Patient #1 to Receiving Hospital A in a locked police car. The medical record did not contain evidence that the CAH arranged to transport Patient # 1 to Hospital A by an ambulance equipped to provide treatment in case of a seizure or other adverse drug overdose reaction.

At 5:32 PM, Sheriff's Deputy C and Patient #1 arrived at Receiving Hospital A. Sheriff's Deputy C requested Receiving Hospital A's ED staff provide Patient #1 a medical screening examination.

2. Review of the "RULES AND REGULATIONS OF THE MEDICAL STAFF OF VIRGINIA GAY HOSPITAL, INC.", approved 12/21/10, revealed in part, "Virginia Gay Hospital ensures provision of the initial examination and stabilization of each person who comes to the Emergency Department."

During an interview on 2/8/12 at 2:10 PM, Physician's Assistant B stated they failed to order a blood test to determine the amount of Tylenol in Patient #1's blood. Additionally, Physician's Assistant B stated they did not call the Poison Control Center to obtain information on the management of Patient #1's intentional overdose of Topamax.

3. Review of the policy "TRANSFERRING OF PATIENTS FROM THE [EMERGENCY ROOM]", reviewed 2/9/12, revealed in part, "Transfers must be completed with appropriate equipment and personnel. Patients will not be transferred by private car or officer's vehicle."

During an interview on 2/9/12 at 4:30 PM, Director of Nursing J stated the CAH ED staff normally transferred patients from the CAH's ED to another hospital via an ambulance. Director of Nursing J stated Patient #1 was not transferred by an ambulance, and instead Patient #1 was transferred in a sheriff's deputy's car. See C-2409 for additional information.

4. Review of the policy "TRANSFERRING OF PATIENTS FROM THE ER", reviewed 2/9/12, revealed in part, "... a physician has signed a certification ... that the medical benefits reasonably expected from appropriate medical treatment at another facility outweigh the increased risks to the individual ..."

During an interview on 2/9/12 at 4:45 PM, Director of Nursing J stated Physician's Assistant B failed to certify in writing that the medical benefits of transfer prior to stabilization outweighed the risks associated with transferring Patient #1 to Hospital A; or that Physician H countersigned PA B's certification. See A-2409 for additional information.

5. Review on 2/9/12 at 2:30 PM of: the policy "Open Communication", reviewed 2/12; "BYLAWS OF THE MEDICAL STAFF" and "RULES AND REGULATIONS OF THE MEDICAL STAFF OF VIRGINIA GAY HOSPITAL, INC.", approved 12/21/10; revealed they lacked a policy prohibiting the hospital administrative staff from penalizing, or taking adverse action, against a physician or qualified medical person if they refused to authorize the transfer of a patient with an unstable emergency medical condition.

During an interview on 2/9/12 at 3:00 PM, the Director of Nursing stated the Critical Access Hospital lacked a policy that protected a physician, or qualified medical person, from retaliation if they refused to authorize the transfer of a patient with an unstabilized emergency medical condition.

Based on document review and staff interview, the Critical Access Hospital (CAH) Emergency Department (ED) staff failed to appropriately transfer 1 patient (Patient # 1) with an unstable emergency out of 30 medical records selected for review from 8/1/11 to 2/8/12. The Director of Nursing stated CAH ED staff initiated approximately 4 involuntary court commitments for patients with psychiatric and substance abuse emergencies per year.

Failure to arrange an appropriate transfer including the use of appropriate personnel and equipment placed the patient at risk for an unsafe transfer and unrecognized symptoms of deterioration and potentially life threatening complications.

Findings include:

1. Review of Patient #1's ED Medical Record on 2/8/12 at 1:30 PM, revealed an ambulance arrived at the patient's home at 11:39 AM on 1/20/12. The ambulance report specified Patient # 1 was visibly upset, aggressive and combative and admitted to taking pills to harm themself. Law enforcement arrived, and further documentation revealed that Patient # 1 began to ingest a "hand full of additional various medications" in front of the police, and they could not stop Patient #1 from ingesting the pills.

Patient #1 arrived in the ED at 12:25 PM, and ED nursing staff immediately placed Patient #1 in an ED room. Registered Nurse (RN) A documented in the "INITIAL ASSESSMENT" Patient #1 admitted to "taking an overdose of ... prescribed medication Topamax and that Patient # 1 stated [they] took about 20 pills today, and half a bottle (approximately 60 pills) yesterday. Further documentation revealed "[Patient #1] knows that seizures can be a side effect of too much Topamax." At 12:40 PM blood and urine specimens were obtained for testing. Physician's Assistant (PA) B examined Patient # 1 and documented that the patient had been feeling quite depressed because a family member had abused another family member, and that the patient had a history of "some harmful behaviors", substance abuse, and previous psychiatric hospitalizations. At 1:51 PM PA B filed an application with the county court to involuntarily commit Patient #1 to a hospital for treatment. At 2:50 PM the ED nurse documented that Family Practice Physician H came to the ED and tried to talk with Patient # 1 but she ran out of the ED and law enforcement was contacted. At 3:05 PM the ED nurse documented that law enforcement returned Patient # 1 to the ED and stayed at the bedside until discharge at 4:38 PM for transport to Hospital A by law enforcement vehicle. There was no evidence in the medical record that the ED contacted poison control for guidance on treating Patient # 1's Topamax overdose combined with unknown other medications, or that PA B consulted with Physician H, or that Physician H certified that the medical benefits of transfer prior to stabilization outweighed the risks; or that to minimize the risks of transfer, arrangements were made for transport by an ambulance with the appropriate monitoring equipment. The medical record also did not contain evidence that the ED contacted Hospital A to ensure it had the capacity to provide Patient # 1 with stabilizing treatment.

2. Review of the CAH's policy "TRANSFERRING OF PATIENTS FROM THE [EMERGENCY ROOM]", reviewed on 2/9/12, revealed in part, "Transfers must be completed with appropriate equipment and personnel. Patients will not be transferred by private car or officer's vehicle."

3. During an interview on 2/8/12 at 4:00 PM, Family Practice Physician H stated he did not believe the ED staff called the Poison Control Center to determine how to treat Patient #1's intentional overdose of Topamax.

4. During an interview on 2/8/12 at 4:30 PM, RN A stated EMS staff walked Patient #1 from the ambulance to the ED. RN A stated Patient #1 required a medical screening examination and stabilizing treatment because Patient #1 had taken an overdose of medication in front of the EMS staff. RN A stated they, and PA B, completed the paperwork to involuntarily commit Patient #1 to a hospital for treatment of the Topamax overdose. After RN A and PA B completed the paperwork, Social Worker D took the paperwork to the court house, and Magistrate E signed the committal paperwork.

5. During an interview on 2/8/12 at 2:10 PM, PA B stated EMS staff told them Patient #1 had taken "a handful of pills while EMS was on scene." Patient #1 stated she had taken 20 pills of Topamax (5 times the usual daily dose) that day, and a lot the prior day. PA B stated a side effect of the overdose was an increased risk of seizures and EKG changes. The medical record did not contain evidence that the CAH staff performed an EKG, or thoroughly evaluated which pills Patient #1 ingested, or directly consulted with poison control regarding Patient #1's overdose.

PA B stated they ordered a urine drug screen on Patient #1. PA B stated since Patient #1 tested positive for acetaminophen in the urine, a blood test was indicated to determine if Patient # 1 had a dangerous level of acetaminophen in the blood. PA B stated they decided Patient #1 needed involuntary commitment to a hospital because Patient #1 did not want treatment for the drug overdose, and because Patient #1 had made statements threatening to harm self and others. After PA B completed the application for involuntary commitment, PA B stated the county court and social services staff took over the process, and located an available facility to provide Patient #1 the needed medical and psychiatric care.

PA B stated they consulted with Physician H, and Physician H decided Patient # 1 could be transported to Hospital A by the Sheriff's Deputy's car.

6. During an interview on 2/9/12 at 4:45 PM, Director of Nursing J stated the medical record lacked evidence that PA B or Physician H certified that the medical benefits of transfer prior to stabilization outweighed the risks of transferring Patient #1 to Hospital A.

7. During an interview on 2/8/12 at 3:40 PM, Clerk of the Court F stated after PA B and RN A had filed the application to involuntarily commit Patient #1, the county Social Services staff attempted to find a facility to accept Patient #1 for treatment. The Social Services staff arranged an accepting facility, because if the Social Services staff did not arrange for the accepting facility, the county would refuse to pay for the patient's hospitalization. After the Social Services staff found a bed, Magistrate E gave the order to involuntarily commit Patient #1 to Hospital A. Clerk of the Court F stated they assumed the CAH ED staff determined whether Patient #1 required transportation to Hospital A by ambulance or by a sheriff's deputy.

8. During an interview on 2/8/12 at 3:20 PM, County Social Services Administrative Assistant G stated they received a call from Clerk of the Court F informing them to find an inpatient facility to treat Patient #1 following an intentional overdose of Topamax. Administrative Assistant G called Hospital B, but Hospital B did not return the call in a timely manner. Administrative Assistant G then called Hospital A. After Hospital A accepted Patient #1 for treatment, Administrative Assistant G notified Clerk of the Court F.

9. During an interview on 2/9/12 at 11:41 AM, Magistrate E stated they ordered Patient #1 to receive involuntary mental health treatment at Hospital A because Patient #1 had consumed a large quality of Topamax pills, which Magistrate E assumed was potentially lethal. Additionally, while Patient #1 was at the hospital, Patient #1 had stated they would take an additional overdose of medication if they left the hospital. Magistrate E stated the normal procedure was to have a sheriff's deputy transport anyone who was involuntarily committed. Magistrate E relied on the hospital staff to inform Magistrate E of the need to transport a patient via ambulance. Magistrate E stated they did not have any medical training, and had to rely on the medical opinion of the hospital's ED staff to know when to issue a court order for ambulance transportation to another hospital.

10. During an interview on 2/8/12 at 4:30 PM, RN A stated they thought Hospital B had accepted Patient #1. However, when Sheriff's Deputy C arrived to transport Patient #1, Sheriff's Deputy C stated they had a court order to transport Patient #1 to Hospital A.

11. During an interview on 2/8/12 at 3:00 PM, Sheriff's Deputy C stated they received information from their dispatcher to transport Patient #1 from the ED to Hospital A. Sheriff's Deputy C was aware Patient #1 had intentionally overdosed on medication. Sheriff's Deputy C stated they accompanied Patient #1 to Hospital A. Sheriff's Deputy C stated they had minimal medical training, and could only provide minimal support if Patient #1 had any medical problems during transport to Hospital A. The only treatment Sheriff's Deputy C could provide was to contact the dispatcher, request an ambulance, turn on the car's emergency lights and sirens, and drive very fast to meet the ambulance.