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BAYLOR SCOTT AND WHITE MEDICAL CENTER CARROLLTON 4343 NORTH JOSEY LANE CARROLLTON, TX 75010 Nov. 5, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on record review and interviews, it was determined that Hospital A failed to comply with 489.24(e)(1)-(2) for one of one patient (Patient #7) in that staff at Hospital A's Emergency Department (ED) discharged Patient #7 to Police to be transported to Hospital B without contacting Hospital B for available space and qualified personnel prior to patient transfer. Hospital B was on divert at the time Patient #7 was transferred to Hospital B.

Findings included:

Hospital A ED Nurses Notes dated 09/28/14 reflected Patient #7 had been brought into the ED per Emergency Medical Services (EMS) Personnel at 17:05 after the patient had been found unresponsive at a recreation center. The patient had used Heroin. Patient #7 had made suicidal comments the night before. At 18:35 Patient #7 was discharged to the police department "...to be taken to...[Hospital B]."

Hospital A ED Physician Notes dated 09/28/14 at 18:11 by Hospital Personnel #9 noted that Patient #7 was "...very hostile and aggressive..." The plan was to discharge Patient #7 to police for transport to Hospital B "...for further mental evaluation and be cleared of any suicidal ideations." There was no documentation that Hospital B was contacted prior to the Patient #7's transfer or that Hospital A completed a Memorandum of Transfer (MOT) to Hospital B for Patient #7.

Hospital A Personnel #9 was telephone interviewed on 11/05/14 at 15:05 and asked whether Hospital B was contacted for a transfer agreement before Patient #7 was transported to Hospital B. Hospital A Personnel #9 stated, "No."

Hospital A Personnel #7 denied during an interview on 11/05/14 at 14:40 that any psychiatric facility was contacted before transporting the patient to Hospital B.

Hospital B's Psychiatric Emergency Services documentation reflected Patient #7's involuntary admission on 09/28/14 at 19:19. Admitting Diagnoses included Opioid Abuse.
Patient #7 was " ...visibly shaking and tearful ...suicidal..."

Hospital A's EMTALA Stabilization Policy and Procedure BMCC.ADMIN.026.P dated 05/2013 reflected " ...the transferring Hospital should document its communication with the receiving Hospital ...the receiving facility should have available space and qualified personnel for the treatment of the individual ...[and] should agree to accept the transfer of the individual ..."

Hospital A's Emergency Department Nursing Standards of Care Policy BMCC.ED.027.P dated 05/2013 noted " ...patients transferred to another facility require a Memorandum of Transfer ..."
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on record review and interviews, Hospital A failed to provide an appropriate transfer for one of one patient (Patient #7) in that staff at Hospital A's Emergency Department (ED) did not contact Hospital B in order to secure the receiving hospital had available space and agreed to accept Patient #7. Hospital B was on divert at the time Patient #7' was transferred to Hospital B.

Findings included:

Hospital A ED Nurses Notes dated 09/28/14 reflected Patient #7 had been brought into the ED per Emergency Medical Services (EMS) Personnel at 17:05 after the patient had been found unresponsive at a recreation center. The patient had used Heroin and had been treated at Hospital A's ED two days prior for drug abuse. Patient #7 had made suicidal comments the night before. At 18:35 Patient #7 was discharged to the police department "...to be taken to...[Hospital B]" and the order for a mental heath consultation was canceled because the patient "refused."

Hospital A ED Physician Notes dated 09/28/14 at 18:11 by Hospital Personnel #9 noted that Patient #7 was "...very hostile and aggressive...uncooperative with obtaining diagnostics and seeking mental health evaluation..." The plan was to discharge Patient #7 to police for transport to Hospital B "...for further mental evaluation and be cleared of any suicidal ideations." Clinical impressions included Drug Abuse and Suicidal Ideation. There was no documentation that Hospital B was contacted for a transfer agreement or a Memorandum of Transfer (MOT) had been completed prior to transferring Patient #7 to Hospital B.

Hospital A Personnel #9 was telephone interviewed on 11/05/14 at 15:05 and asked whether Hospital B was contacted for a transfer agreement before Patient #7 was transported to Hospital B. Hospital A Personnel #9 stated, "No."

Hospital A Personnel #7 stated during an interview on 11/05/14 at 14:40 that Patient #7 was assessed to be suicidal and was placed on suicidal precaution including clearing the patient ED room of objects potentially dangerous for self-harm and dressing the patient in paper scrubs. Hospital A Personnel #7 denied any psychiatric facility was contacted before transporting the patient to Hospital B and "that is not the norm."

Hospital B's Psychiatric Emergency Services documentation reflected Patient #7's involuntary admission on 09/28/14 at 19:19. Admitting Diagnoses included Opioid Abuse.
Triage documents dated 09/28/14 at 19:21 noted the patient had a previous suicide attempt by overdose " ...a few days ago." The patient was " ...visibly shaking and tearful ...denies detoxing ..." Identified problems included that the patient was "suicidal."

Hospital A's EMTALA Stabilization Policy and Procedure BMCC.ADMIN.026.P dated 05/2013 reflected " ...the transferring Hospital should document its communication with the receiving Hospital ...the receiving facility should have available space and qualified personnel for the treatment of the individual ...[and] should agree to accept the transfer of the individual ..."

Hospital A's Emergency Department Nursing Standards of Care Policy BMCC.ED.027.P dated 05/2013 noted " ...patients transferred to another facility require a Memorandum of Transfer ..."