HospitalInspections.org

Based on document review and staff interview, it was determined the hospital failed to:

a. document and retain medical records for patients who were transferred from sending hospitals. See tag A-2403;

b. screen and stabilize or execute an appropriate transfer for two mental health patients who arrived at the Integris Baptist Medical Center Spencer campus. See tag A-2406; and

c. the hospital failed to accept transfers from a sending hospital when it had the capacity and capability to provide specialized care for two mental health patients who were transferred to the hospital. See tag A-2411.

This had the potential to affect all patients who arrived at the Integris Baptist Medical Center Spencer campus.

Based on document review and interview, it was determined the hospital failed to document and retain medical records for patients who were transferred from sending hospitals to the Integris Baptist Medical Center Spencer campus. The hospital identified two patients who were transferred to the Spencer campus from a sending hospital.

Findings:

On 06/03/2016, the hospital documented in an e-mail to the Oklahoma State Department of Health that a male patient was inappropriately transferred to Integris Spencer on 05/06/2016 and another male patient was inappropriately transferred to Integris Spencer on 05/18/2016. The hospital alleged that both patients were transferred directly to the Integris Spencer campus from the sending hospital without acceptance from Integris Baptist Medical Center.

During the complaint survey, the Spencer campus staff were asked for documentation of these transfers such as a medical record, log, occurrence report, security officer report or other record. The staff stated they did not have any documents related to these events and the patients had no medical records sent with them from the receiving hospital.

The staff stated it was not the hospital's practice to document a record of direct transfers into the Spencer campus, so they were unable to identify all patients who were transferred in from other hospitals. It could not be determined if there were any other similar transfers at the Spencer campus.

During interviews, the staff stated that even though they did not have any documentation, they could identify patient #1 because they were familiar with him as he had been a patient at the Spencer campus previously. They also stated they only had a physical description of patient #2 that they provided from memory.

On 06/07/2016, it was confirmed through a review of the sending hospital's emergency department log for May 2016 that these two patients had been seen at the sending hospital on 05/06/2016 and 05/18/2016.

The sending hospital's emergency department record for patient #1 documented on 05/18/2016, "... chief complaint - pt. has bed at Integris psych unit but needs medical clearance..."

The sending hospital's emergency department medical record for patient #2 was dated 05/06/2016 and documented details about the patient that matched the description given by the Integris Spencer staff. The record was unclear about where the patient was transferred.

Integris Baptist Medical Center had no policy that directed staff at the Spencer campus to document transfers from other hospitals.

Based on document review and staff interview, it was determined the hospital failed to screen and stabilize or execute an appropriate transfer for two mental health patients who arrived at the Integris Baptist Medical Center Spencer campus.

Findings:

A hospital policy, dated 6/15 and titled, "EMTALA Requirements and Flow Chart" documented, "The purpose of this policy is to set forth the requirements related to emergency medical screening... Patient comes to hospital property (on or off campus) requesting treatment for emergency condition... hospital provides triage... hospital provides medical screening examination by qualified medical personnel... 'Facility' means... any facility that is located off the main hospital campus but determined by the Health Care Financing Authority to be a hospital department... All patients presenting for treatment will receive, after initial triage, a medical screening examination by qualified medical personnel to determine whether an emergency medical condition exists..."

On June 09, 2016, the Integris Spencer staff were asked to describe the events surrounding the arrival of the two mental health patients who presented to the Spencer campus unannounced from a sending hospital. They stated patient #2 arrived to the campus escorted by law enforcement on 05/06/2016 and patient #1 arrived to the campus escorted by law enforcement on 05/18/2016.

Patient #1
Regarding patient #1, staff #8 stated she was notified of the patient's arrival. She stated there was no communication to anyone at the Spencer campus that a patient was expected. She stated she was familiar with the patient because he had been admitted there before.

She stated she asked the patient what was "going on." She stated he said he was upset because the deputy "busted into his house and took him to [sending hospital name deleted]. He did not say specifically why he was then brought to Integris Spencer. She stated the patient was in hand cuffs and in the custody of a law enforcement officer.

Staff #8 stated she remembered the patient had a history of alcoholism and "may have had high blood pressure and maybe cardiovascular disease," but she couldn't be sure.

She was asked if the patient was evaluated by taking vital signs, assessment of symptoms, etc., by herself or any of the nursing staff. She stated he was not evaluated. She was asked if she obtained any other information about the patient's presenting symptoms. She stated she did not. She stated it was customary to assess the patient only after admission to an inpatient unit.

Staff #7 stated she saw the patient with the law enforcement officer and asked the house supervisor to find out "what was going on." She stated she was told the sending hospital transferred the patient to Integris Spencer. Staff #7 stated the hospital had no knowledge of the transfer and there was no accepting physician. She stated no medical record was sent with the patient.

She stated she spoke with the sending hospital's emergency department physician who told her the patient was seen by the previous shift physician and the record showed the patient had not had any lab studies or EKG, but a review of systems was done. The emergency department physician stated the previous shift ED physician had "medically cleared" the patient for transfer and documented the patient as "stable."

The sending hospital's medical record for patient #1 documented he had a history of suicide attempts including overdose, and alcohol and drug abuse. The sending hospital's ED physician documented the patient appeared to be "slightly intoxicated" while he was at that hospital.

Staff #7 stated she did not believe the sending hospital provided an adequate medical screening examination prior to the transfer and therefore the patient was not determined to be appropriate for admission to the Spencer psychiatric unit.

She was asked if she evaluated the patient. She stated, "He looked OK to me, stable, no sweating and no tremors as if going through withdrawal." She stated she did not speak to the patient or to the law enforcement officer and did not perform a psychiatric evaluation.

She was asked what happened next with the patient. She stated she told the sending hospital ED physician that "since the [sending hospital] ED physician started the work-up, he should probably finish it and that it was possible to start over at the Integris Baptist Medical Center ED but it was probably better for the patient to go back to [the sending hospital]."

She stated the patient then left with the law enforcement officer and she assumed the patient went back to the sending hospital.

The sending hospital had no record the patient returned to them. Since no one could identify the law enforcement officer, it could not be determined where the patient went after he left Integris Spencer.

Staff #9 was asked about his recollection of the events with patient #1. He stated he and the law enforcement officer escorted the patient to the mobile assessment team room that was used to do a telemedicine evaluation by mental health staff at the Integris hospital main campus. He stated the patient became upset when it became clear to him that the staff were not going to admit him to the unit. He stated the patient wanted to be there. He stated the patient became so upset that he refused to sit in a chair that was offered to him and instead sat on the floor in the evaluation room.

Staff #9 stated the patient was not evaluated by telemedicine and eventually the law enforcement officer and the patient were told he was not going to be admitted and that the officer should take the patient back to the sending hospital.

Staff #9 was asked how other "unannounced patients" were handled at the Spencer campus. He stated they were always told to go back to where they came from or told to go to an emergency room." He stated even some patients that were accepted for admission were sent away because the staff thought they needed a medical clearance first. He stated unannounced patients and patients who were expected for admission always left the facility by the transportation used at arrival.

Patient #2
Patient #2 was seen in the emergency department at the sending hospital on May 06, 2016 for a suicide attempt and lacerations to both forearms. The medical record was unclear as to where the patient was transferred.

The staff at Integris Spencer stated they had heard about this patient's unexpected transfer to the Spencer location but none of them were present when he arrived and they stated they did not know who on staff were involved in the situation.

Staff #8 stated she was present when the patient arrived and the Spencer location had no beds available, so she called the sending hospital. The sending hospital could not give her the name of the accepting physician for Integris, so she said she told the sending hospital they were sending the patient back to them. She stated the patient did not receive any type of evaluation at the Spencer campus and the patient left with the law enforcement officer. She stated the hospital had no documentation of this event.

Other staff verified Integris Spencer had no documentation of this patient's arrival or of any actions taken on his behalf.

Staff #10 verified the Spencer location did not document walk-in patients or transfers in from sending hospitals. He stated that walk-in patients were told to go to the nearest emergency department or drive to the Integris Baptist Medical Center main campus ED. He stated that patients who arrived with law enforcement were told the same thing.

He recalled a situation approximately six months prior when a patient walked in with symptoms that he said "met the criteria for admission." He stated there was no bed available at the Spencer location so he called another hospital with psychiatric services and secured a transfer to a bed there. He stated law enforcement was called to transport her. He was asked if there was any record of this event. He stated there was not.

Staff #10 was asked if all walk-in patients were evaluated as he had done for this patient. He said they were not. He stated that after normal business hours, the Integris mobile assessment team (MAT) assessed patients by telemedicine. However, not all walk-in patients were assessed by MAT. He stated the hospital did not provide MAT assessments unless a bed was available at the Spencer location. He again stated those patients were told to go to an emergency room. He stated that patients who were suicidal or homicidal were transported to an ED by law enforcement.

The hospital did not provide a policy and procedure that directed the Spencer staff on the use of the telemedicine assessment services.

Staff #10 was asked if any walk-in patients were assessed for medical problems at the Spencer campus. He stated they were not, unless during his psychiatric evaluation a medical problem was discovered. He said those patients were told to get a medical clearance at a hospital emergency department before they could be admitted to the Spencer unit.

A hospital policy, dated 10/24/15 and titled, "Patient Transfers - EMTALA" documented, "... In the event the patient does not present him/herself to the [Integris Baptist Medical Center Emergency Department] or labor and delivery unit and is identified as seeking or in need of emergency medical care, the patient will be assisted to the [Integris Baptist Medical Center Emergency Department]..."

The hospital's QAPI plan for 2016 did not include assessment of EMTALA compliance.

Based on document review and staff interview, it was determined the hospital failed to accept transfers from a sending hospital when it had the capacity and capability to provide specialized care for two mental health patients who were transferred to the hospital.

Findings:

On May 06, 2016 and May 18, 2016, the Integris Baptist Medical Center Spencer campus, a mental health inpatient treatment facility, received patients transferred from a sending hospital. The sending hospital determined these patients needed emergent inpatient psychiatric care.

The staff stated that on May 06, 2016 the Spencer facility did not have the capacity to admit the patient (patient #2) who they said arrived without notice from a sending hospital. Integris Spencer did not have documentation of this event and did not have documented evidence the facility was at capacity for this date.

The patient was sent away with a law enforcement officer, allegedly to return to the sending hospital. The sending hospital did not have the specialized capabilities to care for psychiatric patients.

The staff stated on May 18, 2016, another patient (patient #1) arrived without notice from the same sending hospital. The staff stated this patient was refused admission because he did not have an adequate medical clearance examination at the sending hospital emergency department. When the staff were asked if the Spencer campus had the capacity to admit the patient, they stated they did not know if a bed was available because "it (the situation) didn't get to that point."

This patient was sent away with a law enforcement officer allegedly to return to the sending hospital. The sending hospital did not have the specialized capabilities to care for psychiatric patients.

A hospital policy, dated 10/24/15 and titled, "Patient Transfers - EMTALA" documented, "... Requirement to accept transfers. [Integris Baptist Medical Center] must accept emergency patient transfers from other facilities if the individual requires specialized capabilities or facilities that are not offered or not immediately available at the transferring hospital... if [Integris Baptist Medical Center] has the capability and the capacity to treat the individual..."