The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on record reviews and interviews, it was determined the facility failed to develop, implement and ensure safety and care of patients during transport. This failure affected 2 of 5 sampled patients (Patient #6 and #7).

The findings included:

1) Clinical record review revealed, Patient # 7 (MDS) dated [DATE] due to suicide attempt and depression.

A report of Law Enforcement Officer Initiating Involuntary Examination dated 11/17/15 at 12:00 AM documents, the patient took an unknown amount of antidepressant pills and made numerous superficial cuts on both forearms.

The history and physical dated 11/17/15 documents, the patient was admitted to the pediatric intensive care for medical management and deemed medically clear to transfer for inpatient psychiatric treatment on 11/23/15.

The transfer out form dated 11/24/15 documents the transport was set up by the case manager, Patient # 7 was discharged at 8:15 AM.

The transfer Center Inpatient Transfer Record dated 11/24/15 documents, the mode of transportation was noted as "AMS."

The Nursing Discharge Summary dated 11/24/15 documents, Patient # 7 was transferred to another facility at 8:15 AM, the mode of transfer, noted other "AMS."

Interview with the Assistant Chief Nursing Officer (ACNO), who was navigating the electronic record, on 01/06/16 at 4:02 PM revealed, the term "AMS" most likely is an error and it should read "AMR" A..... R.... S...., a medical transport company.

Interview with the Case Manager on 01/06/16 at 4:10 PM revealed despite being identified on the transfer out form as the person who set up transportation for Patient # 7, she does not recall setting up the transportation for this patient.

Interview with the Director of Case Management conducted on 01/06/16 at 4:16 PM revealed, transportation arrangements are done according to insurance coverage. Most of the time involuntary admissions would be transported via "AMR," or sometimes they used a company called "OW," a non-medical transport company.

Interview with the Director of the Emergency Department (ED) on 01/06/16 at 4:25 PM revealed, the facility uses Emergency Medical Services (EMS) to transport pediatric and adolescent patients under involuntary examination from the emergency department to a receiving facility.

Subsequent interview with the ACNO on 01/06/16 at 4:32 PM revealed, the facility has no policy and procedures or guidelines for safe transportation of minors under involuntary admission to a receiving facility.

Upon request, on 01/06/16 at 4:43 PM and 4:49 PM, the ACNO contacted transportation companies, "OW" and "AMR," respectively and none of the companies had records of transporting Patient # 7 out of the facility on 11/24/15.

Interview with the ACNO on 01/08/16 at 8:58 AM revealed, after further research, the facility has confirmed Patient # 7 was transferred out of the facility via taxi, on 11/24/15 with one male driver. The ACNO explained, the case manager did set up the transportation and used the contracted company assigned by the insurance company. The transportation company denied having knowledge that Patient #7 was placed under an involuntary admission and therefore sent transportation via Taxi with one male driver to transport the under age female.

A phone interview with the Registered Nurse who discharged Patient # 7, on 01/08/16 at 9:28 AM revealed, all the discharge arrangements were completed during the night shift, as the patient was scheduled for discharged at six in the morning. Her involvement was limited to updating the time of discharge on the record. The Nurse stated, a man came up to the floor stating he was here to transfer the patient to the receiving facility. The Nurse could not recall if he had any type of identification and does not recall who escorted the patient out of the facility. She assumed the man was from the receiving facility. The medical records were provided to this individual in an envelope.

2) Clinical record review conducted on 01/06/16 revealed Patient # 6, a female adolescent (MDS) dated [DATE] due to suicidal ideations. The Patient was deemed an involuntary admission and subsequently transferred to a pediatric/adolescent receiving facility for psychiatric services.

Further review of the transfer out from dated 11/13/15 revealed, Patient # 6 was transported via non-emergency transport "OW."

Upon request, the ACNO contacted the transportation company "OW" on 01/06/16 at 4:38 PM. The representative stated over the phone, Patient # 6 was transported to the receiving facility on 11/14/15 with a male driver. The representative explained on most occasions, adolescent and pediatric patients under involuntary admission would be transported with two attendants, but this transport occurred on a Saturday morning at 6:30 AM and only one driver was available.

Interview with the ACNO on 01/08/16 at 8:58 AM revealed after further research, the means of transportation provided by company "OW" were not appropriate. The vehicles in use have no safety features, including child proof locks. If a patient wants to leave the vehicle, they could do so.