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SOUTHERN NEVADA ADULT MENTAL HEALTH SERVICES 6161 W CHARLESTON BLVD LAS VEGAS, NV 89146 Nov. 12, 2013
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview the facility failed to ensure transfers were screened and carried out following regulatory requirements as required for 5 of 49 sampled patients (Patient #3, Patient #18, Patient #35, Patient #39, and Patient #7).

Findings include:

Patient #3

Patient #3 presented to the Outpatient (OP) Clinic on 10/7/13 with complaints of hearing voices telling her to go naked, and everyone was threatening her with knives.

Patient #3's skilled nurse's notes from the clinic documented Patient #3 had a previous admission at the facility with an incidence of assault.

During the nurse assessment, Patient #3 became violent and started to assault the nurse.

Patient #3 was placed on a Legal hold. Since there were no beds available in the facility, 911 emergency was called for transfer to another facility.

Patient #3's COBRA (Consolidated Omnibus Reconciliation Act) transfer form documented:
- Receiving Facility - Per Routine
- Receiving Physician - Blank
- Person Accepting - Blank
- Verbal Report Given - Blank
- Phone - Blank

Patient #3's medical record included a Legal 2000 form which indicated the patient was extremely agitated and assaulted a staff member.

There was no documented evidence of any medical record information sent to the receiving facility. There was no documented evidence a verbal report was given to the receiving facility.

Patient #18

Patient #18 (MDS) dated [DATE] with complaints of being depressed and suicidal thoughts. The patient was evaluated by the psychiatrist and placed on a Legal 2000. The patient was transferred to another hospital for medical clearance.

Patient #18's COBRA (Consolidated Omnibus Reconciliation Act) transfer form documented:
- Receiving Facility - Per Routine
- Receiving Physician - Blank
- Person Accepting - Blank
- Verbal Report Given - Blank
- Phone - Blank

Patient #18's medical record included a Legal 2000 form which indicated the patient was depressed and increased risk for self harm.

There was no documented evidence of any medical record information sent to the receiving facility. There was no documented evidence a verbal report was given to the receiving facility.

Patient #35

Patient #35 (MDS) dated [DATE] with complaints of active hallucinations. The patient was seen by a nurse and a psychiatrist.

Based on the psychiatric assessment, Patient #35 was placed on a Legal 2000 and transferred to (Name) Hospital by AMR (American Medical Response) ambulance for medical clearance and evaluation, as per the nurse's notes.

As per the nurse's note, a copy of the Legal 2000 form was sent with the patient. The form documented the patient was psychotic and could not care for self.

There was no documented evidence a COBRA (Consolidated Ominbus Reconciliationc Act) transfer form was completed. There was no documented evidence a report was provided to the receiving facility. There was no documented evidence copies of any additional medical record information was sent with the patient including the most recent vital signs.

Patient #39

Patient #39 (MDS) dated [DATE] with complaints of suicidal ideations. The patient was hearing voices to hurt himself. The patient was assessed by the nurse and psychiatrist.

Based on the psychiatric assessment, Patient #39 was placed on a Legal 2000 and transferred to (Name) Hospital by ambulance for medical clearance and evaluation, as per the nurse's notes. The nurse's notes indicated a report was given to a nurse and physician at the receiving hospital.

There was no documented evidence a COBRA transfer form was completed. There was no documented evidence copies of the medical record including the assessments by the nurse and psychiatrist were sent with the patient.

On 11/12/13 at 3:00 PM, the Hospital Administrator (Adm) verbalized when someone showed up requesting services after the clinic was closed, there was no requirement for the nurse to do an assessment. If there was a person needing immediate assistance, 911 emergency should called. There was no log maintained of people who presented to the facility after hours. If 911 was called and there was a determination the patient was a legal 2000, there was no requirement for the nurse to complete a transfer form, as the person was not an admission to the facility.

The Adm added, the determination as to which the facility the patient was referred to was totally the decision of the EMS (Emergency Medical Staff). There was no communication between the staff at facility and the receiving facility.

The facility policy titled Interhospital Patient Transfers and COBRA Compliance, review date 5/13 documented:
- A. The Patient Transport Form is to be used anytime a patient from SNAMHS is transferred to another facility including, acute care medical facility for inpatient or emergency department care....
- 1. c. Enter reason for transfer and name of receiving facility.
- d. Enter the name of the receiving physician and name of the person authorized to accept the patient...
- e. Enter the name of the person receiving your verbal report and the phone number at which this person can be reached."







Patient #7

Patient #7 and a case worker initially (MDS) dated [DATE] when the out-patient clinic and hospital lobby were closed. The patient and the case worker arrived by car from California. A Legal 2000 was initiated by the house supervisor for poor insight, poor judgement, no social support and unable to care for self. The patient was transferred to an acute care hospital on [DATE]. The patient was admitted to the acute care hospital from 8/17/13 to 8/20/13, with diagnosis of psychotic disorder. The patient was transferred back to the facility on [DATE].

The acute care hospital Psychiatric consultation dated 8/18/13, documented:

"...History Of Present Illness: This is a psychiatry evaluation for a [AGE] year-old female with unknown past psychiatric history presenting to the hospital on legal 2000 stating that she is unable to care for herself. The patient states that she was essentially dumped here by her case manager yesterday. Is not able to state any reason why she was essentially dumped here by someone. She is very primitively self focused on discharge throughout the interview. She appears very, very guarded and give conflicting information throughout the interview. She does present extremely flat and guarded with very concrete thought process. She states that she has been taking her medications although she states that she takes medications for headaches. She states initially that she has never seen a psychiatrist in the past. However, upon learning that she is not leaving the hospital immediately today she does eventually open up that she has seen a psychiatrist in California just before coming to the hospital here. She states "I have been locked up for 7 months". She persist that she wants to leave the hospital, eventually she states that she wants to leave the hospital so she can "get a beer". She does state that she is taking her medications although she cannot name them off the top of her head. She states that she has been living in a shelter. She states that she has several family and friends in town. However again, she is getting very conflictual information throughout the interview. She denies actual psychotic symptoms at this time including auditory or visual hallucinations or paranoid ideation. However, after the interview she might be possibly responding to internal stimuli in her room. She otherwise denies any suicidal ideation. She denies other pertinent positives on psychiatric review of systems. The patient began asking from her room "please do not mess with my brother"...."

From 11/7/13 to 11/8/13 several staff members were interviewed regarding Patient #7 presenting on the facility grounds on 8/17/13. There were no staff members who recalled the incident. There was no documented evidence a log was completed for patients requiring emergency medical treatment after the out-patient clinic was closed for the day.

On 11/8/13 in the afternoon, it was identified which Registered Nurse (RN) house supervisor was working at the time of Patient #7's incident. The RN house supervisor recalled the incident that occurred on 8/17/13 with Patient #7. The RN house supervisor indicated the patient's case worker dropped the patient off at the facility having the understanding the patient was to be admitted to the facility. The RN supervisor indicated the facility did not receive any information the patient was transferring from a California hospital to their facility. The RN house supervisor indicated the patient could not be admitted to the facility since the out-patient clinic was closed. The RN house supervisor indicated a Legal 2000 was initiated due to his assessment the patient was unsafe and could not be left alone to wander the streets. The RN house supervisor confirmed the incident and assessment was not documented. The security guard daily log had no documented evidence of the incident. The RN house supervisor indicated there was no policy regarding handling of patients who show up to the facility when the out-patient clinic was closed.

Complaint NV 375