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Based on review of medical records, Medical Staff Bylaws, Medical Staff Rules and Regulations, facility policies, staff interviews, personnel files, and credential files, it was determined that the facility failed to ensure compliance with CFR 489.24, for one (1) individual (#2) of twenty (20) sampled patients.

Findings:

Cross refer to A2409 as it relates to failure to ensure that all transfers are appropriate.

Based on review of the medical records, policies and procedures, and staff interviews, it was determined that the facility failed to ensure that their policies and procedures were followed as evidenced by failing to initiate an appropriate transfer for 1 (patient #2) of 10 patients that were transferred in a total of 20 medical records that were reviewed..

Findings:

Review of patient #2's medical record revealed the patient was an uninsured patient who was brought to the ED by a law enforcement officer on 01/17/16 at 6:12 p.m. with a chief complaint of mental health problem. The triage nurse #5 (assessment by a nurse to determine severity of the chief complaint and the priority in which patients will be seen by the provider) noted that the patient was a level 3 acuity. The electronic time noted that the triage assessment occurred at 11:57 p.m. (this is the time documentation was entered into the computer and not the actual time of the assessment). Nurses' notes indicated that the patient was "having a bad day" and that the patient presented to the ED in the custody of a law enforcement officer after an incident where the patient threatened to kill his/her mother and the officer with an axe and to burn down the family home. The nurse also noted that the patient's vital signs (temperature, pulse, respirations, blood pressure, and oxygen saturation) were within normal limits.

Review of the ED physician #2's notes revealed the physician initiated the medical screening examination (MSE) at 6:17 p.m. The physician noted that the patient presented with homicidal ideations. The physician noted that the patient had a history of lyme disease and that the review of systems and physical examination were negative. Physician orders and diagnostic test results revealed normal blood tests and urinalysis, and negative drug and alcohol tests. The physician's notes indicated the patient had homicidal behavior and that the patient was to be transferred to a psychiatric facility.

Further review on the medical record revealed that at 7:54 p.m., nurse #5 noted that he/she spoke with someone at Georgia Crisis and Access Line (GCAL) and that a mobile crisis evaluator would arrive to evaluate the patient in approximately 1 hour. The nurse also noted that the patient had been medically cleared and that a 1013 (Georgia's legal document that allows a patient that is a threat to self or others to be held involuntarily for up to 72 hours) form had been initiated by the ED physician #2. In addition, the nurse noted that the law enforcement officer remained at the patient's bedside. At 9:36 p.m., nurse #5 noted that the Licensed Clinical Social Worker (LCSW) #3/GCAL mobile crisis evaluator was at the patient's bedside.

In addition, the LCSW #3 noted that the patient was brought to the ED by law enforcement due to homicidal ideations and reports that the patient wanted to send his/her mother to heaven. The LCSW noted that the patient attack the patient's mother and the law enforcement officer with an axe and made threats to burn down the family home. The LCSW noted 4 times that the ED physician had ordered the patient to be a 1013. In addition, the LCSW noted that the patient reported hearing voices and commands to push the patient's mother over the railing. The LCSW noted that the patient had previously received inpatient and outpatient psychiatric treatment. The LCSW noted that the plan of care was for the patient to be referred to the receiving facility. At 11:51 p.m., nurse #4 noted that the patient was "transported 1013" to the receiving facility, that the patient had been transferred by the county sheriff's department, and that the LCSW went with the patient. Nurse #4 also noted that the LCSW had called report to the receiving facility. The medical record lacked documented evidence of the 1013 order, the Physician's Certification for Transfer form, or the Nursing Transfer Record.

Review of the facility's policy entitled "Cobra/EMTALA (Emergency Medical Treatment and Labor Act) Guidelines", no policy number, effective 03/04/06, last approved 02/20/15, revealed that if a patient is to be transferred for medical necessity the following guidelines must be followed:
--A physician certification that the risks of transferring the patient are outweighed by the potential benefits. The individual risks and benefits must be documented and the patient's medical record must support these, or
--The patient requests a transfer in writing.
--In addition to the following:
--The receiving hospital must give acceptance ain advance. The acceptance must be documented in the medical record;
--The patient gives written consent for transfer,
--The patient must be transferred by an appropriate medical transfer vehicle. A patient may not be transferred in a private passenger vehicle unless the patient refuses to be transferred by ambulance. The patient's refusal must be in writing.
The physician will order appropriate medical personnel to attend the patient, maintain and/or initiate treatment or medications and manage known potential adverse effects.
Copies of the medical record, x-rays and laboratory tests will accompany the patient when transferred.

During an interview on 02/02/16 at 3:15 p.m., in the Conference Room, physician #2 reviewed the medical record for patient # 2 and stated he/she recalled the patient and filling out a 1013 form. The physician explained that nursing was to make a copy of the record. He /she further stated that ' we did not attempt to transfer the patient; we called GCAL to assist with transferring the patient and obtaining bed placement. I did not complete the transfer form or call to get an accepting hospital or provider, though I normally do. However, with this psychiatric patient the LCSW made all the arrangements for transfer ' . The physician said that he/she questioned the LCSW and the LCSW stated he/she had it covered. The physician said he/she thought it was a new process since the LCSW assured him/her the situation was handled.

During an interview on 02/02/16 at 3:30 p.m., in the Conference Room, nurse #5 reviewed the medical record for patient #2 and stated he/she remembers the patient. The nurse explained that the electronic triage time was the time he/she entered the triage information not the actual time of the triage. The nurse said a law enforcement officer arrived with the patient and remained with the patient. The nurse said that he/she did not think a transfer form was needed for psychiatric patients because the patients were a 1013 and were being transported by law enforcement. The nurse went on to say that he/she thought the transfer form was only for patients who were being transferred by ambulance. The nurse said that the LCSW from GCAL handled the transfer. The nurse stated that he/she left before the patient and was unsure what paperwork went with the patient but that law enforcement agents are not usually given any medical records because of Health Insurance Portability and Accountability Act - the information is usually faxed to the accepting facility.

During an interview on 02/02/16 at 3:00 p.m., in the Conference Room, nurse #4 stated he/she remembers the patient. The nurse stated that on 01/17/16 he/she worked the 7:00 p.m. to 7:00 a.m. shift. The nurse said that he/she thought the day shift had tried to transfer the patient to a number of psychiatric facilities and had exhausted all areas. The nurse said that day shift had then called GCAL to assist with transferring the patient. The nurse said the norm for transfers was to do a nurse to nurse report and physician to physician report. The nurses do the Nursing Transfer Record and the physicians do the Physician's Certification for Transfer form. The nurse explained that the subject transfer did not follow the normal procedure. The nurse said that the 1013 and the patient's medical record were copied and that the LCSW from GCAL gave report to the receiving facility's psychiatric unit. The nurse confirmed that while the patient was in the ED, the law enforcement officer remained at the patient's bedside.

During a telephone interview on 02/02/16 at 3:45 p.m., the LCSW #3 from GCAL confirmed that he/she remembered the patient. The LCSW stated the ED physician had filled out a 1013 on the patient. The LCSW stated that law enforcement transported the patient to the receiving facility. In addition, the LCSW said that he/she did not know anything about EMTALA and that he/she did not make any arrangements for the patient's transfer.

During an interview on 02/02/16 at 2:20 a.m. in the Conference Room, physician #1 (ED Medical Director) stated he/she was familiar with EMTALA regulations. The physician reviewed medical record #2 and stated this was his/her first time reviewing the record. The physician confirmed that he/she could not find the 1013 or transfer forms. The physician said that normally the transfer forms were completed for all transfers.

During an interview on 02/03/16 at 9:45 a.m., in the Conference Room, nurse #7 (Nurse Manager) stated that he/she became aware of the situation on 01/25/16 when the Chief Executive Officer informed him/her that the receiving facility had made a complaint regarding the transfer of patient #2. The nurse said that he/she investigated the matter and did not identify any problems. He/she stated that he/she initially felt that it was a miscommunication because they did not know that the psychiatric unit was part of the receiving hospital. The nurse said that after reviewing the medical record he/she did identify that the transfer was inappropriate because there was no evidence of a 1013 or the transfer certificate. He/she also identified that there was no evidence of an accepting facility, accepting physician, or that the medical record had been sent to the receiving facility.