HospitalInspections.org

Based on document review and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure that the receiving hospital had agreed to accept the patient and had space and qualified personnel available for the treatment of the individual. See deficiency at A-2409 A.

2. The Hospital failed to ensure that the physician completed a written certification for transfer, including the reason for transfer and the risks and benefits associated with the transfer. See deficiency at A-2409 B.

A. Based on document review and interview, it was determined that for 1 of 5 behavioral health patient (Pt. #1) transfer records reviewed, Hospital A failed to ensure that the receiving hospital [Hospital B] had agreed to accept the patient and had space and qualified personnel available for the treatment of the patient.

Findings include:

1. Hospital A's policy titled, "MW [Midwest] Region EMTALA (Emergency Medical Treatment and Labor Act)" (revised 12/09/2024), was reviewed and required, " ...patient may be transferred if hospital staff provide stabilizing treatment for the patient's EMC [emergency medical condition] within the Capacity and Capabilities of the Hospital and sections a-d below are met: ....b) Recipient Hospital: A representative of the Recipient Hospital must confirm prior to Transfer that: (1) The Recipient Hospital has available space and qualified personnel to treat the patient and agrees to accept the Transfer and to provide appropriate medical treatment; and (2) Hospital staff should document any communication with the Recipient Hospital, including date and time of the Transfer request and the name of the person accepting the Transfer in the patient's medical record ..."

2. Hospital A's clinical record of Pt. #1's ED visit on 04/18/2025 was reviewed on 06/03/2025. Pt. #1 presented to the ED on 04/18/2025 at 3:12 PM with a chief complaint of suicidal ideation/SI.

- The Triage Note, dated 04/18/2025 at 3:37 PM included "[Pt. #1] arrived ambulatory through triage with c/o [complaint of] suicidal ideation, with plans to use service weapon. No hx [history] of SI ... Accompanied by fellow officers."

- The Medical Screening Examination/MSE completed by ED Physician (MD#1) on 04/18/202 at 4:35 PM, included "...Patient presents to the emergency room with suicidal ideations. Patient has access to weapons. No acute medical complaints at this time, routine lab work shows no acute medical issues. No indication for any further medical workup at this time. Central access as well as the fellow officers have arranged for inpatient treatment. Patient to be transferred with a certificate via ambulance."

- The Suicide Risk Score completed on 04/18/2025 at 3:38 PM indicated that Pt. #1 was at high risk for suicide. The record indicated that Pt. #1's belongings were secured (Pt. #1 changed into hospital clothes) and a sitter was assigned to monitor Pt. #1 for safety.

- The record indicated that labs were drawn and completed which included: CBC (complete blood count), drug screen, blood alcohol level, comprehensive metabolic panel, pregnancy test. Results were within normal range.

- The Central Access Licensed Clinical Professional Counselor/LCPC (E#1) note, dated 04/18/2025 at 7:02 PM, included "Patient in need of transfer due to on-site BH [behavioral health] unit - no appropriate bed [Hospital Bed Report dated 04/18/2025 indicated the BH units were not at capacity, see interview with E#1 for reason for transfer]. Patient Site Preference 1) [Hospital B] ... EAP [Pt. #1's Employer's Employee Assistance Program] Team Lead [Z#1] requested patient be sent to this facility as this is a facility they use for active duty police, [Z#1 stated that they] called and confirmed patient can be sent there without referral packet being done or RN to RN. PCS (Physician Certification Statement) form completed and placed on chart, called [Ambulance Service] ... scheduled BLS [basic life support] transport."

- Another note by E#1, dated 04/18/2025 at 7:11 PM, included "[Pt. #1] presenting to the emergency room with [Pt. #1's] EAP support team after calling their crisis line and endorsing having suicidal thoughts with a plan to use service gun. Patient was medically cleared and central access evaluated patient. Patient gave consent for EAP team to be in assessment as well as Peer support officer. Also gave verbal consent to provide information to friend at bedside ... Patient reports today everything came to a head, [Pt. #1] reports being in a 'dark place' and stated [Pt. #1] sat with [Pt. #1's] gun in front of [Pt. #1] on bed for a couple hours and eventually called the EAP crisis line. Patient stated prior to today, [Pt. #1] never had suicidal thoughts that were active, only passive death wishes when going through separation and random other points in [Pt. #1's] life. Patient has never attempted suicide, reports unknown mental health history in family. Patient reports reasons to live are daughter. [Pt. #1] reports knowing the impending death of mother from cancer is hard, [Pt. #1] reports great support around [Pt. #1] with EAP and police coworkers ... Above contacts at bedside during whole assessment and vouched for patient's safety. Informed writer [Pt. #1] will be with someone at all times and escorted to the facility, informed writer they took [Pt. #1's] gun and have it secured. EAP reports the facility [Hospital B] patient is transfer[ing] to is the facility they use in these situations, the reason [Pt. #1] came to [this] ED was 'lack of knowledge' [by the officers who brought Pt. #1 here] and usually they transport people in patient's situation directly to the facility [Hospital B] but stated there were many cops at [Pt. #1's] home and [Pt. #1's child] was witnessing this and they felt best situation was to take [Pt. #1] to [this] ED. Informed above [Pt. #1] will need to go via ambulance per protocol as the above mentioned taking [Pt. #1] would be a discharge and it is not safe nor protocol with a suicidal patient, above named all in agreement with ambulance transport and thankful for the help provided in making sure patient is taken care of ... Pt does meet criteria for psychiatric inpatient hospitalization as evidenced by SI with a plan to shoot self with service gun. ED attending notified of treatment plan and is in agreement ... Involuntary petition and certificate were completed ..."

- The record lacked documentation that any contact with Hospital B was made regarding acceptance of transfer of Pt. #1 and/or capacity/capability.

- A Nurse's (E#2) note, dated 04/18/2025 at 7:21 PM, included "Per [E#1] (central access) no report necessary to [Hospital B]. [Ambulance] here - given PCS and face sheet; awaiting belongings."

- Nursing Discharge Note, dated 04/18/2025 at 7:39 PM, included "Patient discharged in the care of ambulance. Transfer charge completed by [E#2]. Patient vitals stable upon transfer. Public Safety has returned personal belongings to patient and they are in the care of [Ambulance Service] for transport. Patient stable upon discharge."

- E#1's Note, dated 04/18/2025 at 7:43 PM, included, "At 9:13 PM and 9:19 PM Writer spoke with staff at [Hospital B], medical director [Z#2] and crisis worker [Z#3], at different times. [Z#2] called asking clarification on the situation as they do not have an inpatient psychiatric unit at their facility. Writer informed [Z#2] we were unaware of this matter, writer was informed via patient's EAP team lead, this is the facility they send their team members to in these situations. [Z#2] asked if an accepting physician was established or called, writer informed [Z#2] no, due to this situation being new and the protocols for police officers being different, writer took the advice of the EAP counselor as [Z#1] best knew their protocols ... Writer also clarified with [Z#3], they are able to send [Pt. #1] back [to Hospital A] and [MD#1] communicated this to [Z#2] as the intention was to be helpful to the patient ...11:15 PM: Received called from [Z#1], indicating [Pt. #1] was being hospitalized in WI (Wisconsin) and writer informed [Z#1] that [E#1] was told the patient is coming back to [Hospital A] and will be hospitalized here ... 11:20 PM: Received call from [Z#3] ... asked when patient would be coming back as it was informed to us by [ED Medical Director MD#2] they called and were sending [Pt. #1] back to [Hospital A]. [Z#3] stated [Z#3] is working on placement in WI as this is patient's wish to stay in WI and is unaware of patient coming back [to Hospital A] ..."

3. Hospital B's clinical record of Pt. #1's ED visit on 04/18/2025 was reviewed on 06/05/2025. Pt. #1 presented to Hospital B's ED by ambulance on 04/18/2025 at 9:22 PM with a chief complaint of suicidal ideation.

- ED Triage Note, dated 04/18/2025 at 9:25 PM, included "Pt arrived to the ED from ambulance with complaints of suicidal ideation. Pt is a [police] officer and wanted to shot self with service weapon. Pt came here from [Hospital A] with no notice of pt coming here. Pt was an involuntary petition in IL (Illinois), pt is voluntary here at this time..."

- The MSE by ED Physician (Z#2), dated 04/18/2025 at 9:27 PM, included "We did notify our emergency department social worker. In addition our staff are working on psychiatric placement for this patient... Patient is agreeable to voluntary psychiatric hospitalization. We are currently pending acceptance at a psychiatric facility. Patient was also accompanied to the hospital by a police officer who reported that they had removed the patient's firearms and that EAP program is involved ... History of Present Illness: [Pt. #1] is a law enforcement officer in Illinois arrived by ambulance to our facility for psychiatric placement transferred from [Hospital A]. Patient has suicidal ideation therefore it was determined [Pt. #1] would need psychiatric hospitalization. I did contact physician [MD#1] after the patient arrived. [MD#1] stated the patient had suicidal ideation and thoughts of killing self with handgun. It was unclear why the patient was transferred to our facility..."

- Crisis Worker (Z#3's) Note, dated 04/18/2025 at 10:48 PM, included "...[Z#3] consulted to assess pt and assist with Mental Health placement ... Patient presented to ED on an involuntary petition hold from Illinois. Due to patient being over state lines and is now in Wisconsin, Illinois involuntary petition documentation does not apply. At this time, patient is voluntary seeking behavioral health treatment in Wisconsin. ED charge nurse and MD spoke with hospital staff at [Hospital A] and was informed that the patient is an active duty police officer in [city name]. [Z#3] was connected with [E#1] who reported that per the [PD-police department] 'employee assistance program', it is their protocol to either bring the patient to a Wisconsin hospital or an Indiana hospital... Social worker informed [E#1] that regardless of [PD] protocol, Wisconsin has different mental health laws than Illinois and cannot accept involuntary petition paperwork ... Patient continues to be voluntary at this time and is willing to seek inpatient treatment in Wisconsin ... 11:30 PM: Social Worker initiated referral at [Hospital C] per pt request to stay in WI but also be 'close to Illinois border.' ... Patient has been accepted ..."

- ED Provider Note, dated 04/19/2025 at 12:12 AM, included "Discussed with psychiatry at [Hospital C] ... [Pt. #1] is agreeable ... Patient accepted for transfer to [Hospital C].

- The record indicated that Pt. #1 was transferred by ambulance to Hospital C on 04/19/2025 at 2:00 AM.

4. The clinical record from Hospital C was reviewed and indicated that Pt #1 arrived via ambulance on 4/19/2025 at 2:45 AM for voluntary psychiatric inpatient admission/treatment. The record indicated that Hospital C accepted the transfer of Pt #1 and included all records from Hospital B were sent to Hospital C. Pt #1 was directly admitted to Hospital C.

5. An interview was conducted with the Central Access LCPC (E#1) on 6/3/2025, at approximately 2:25 PM. E#1 stated that E#1 and MD#1 agreed that Pt. #1 needed inpatient psychiatric hospitalization. E#1 stated that in Pt. #1's case, when the patient and EAP team were notified of the plan, they immediately requested to transfer Pt. #1 to Hospital B in Wisconsin, or a hospital in Indiana (no name was given). E#1 stated that E#1 was not familiar with Hospital B and had never heard of them prior to this encounter. E#1 stated that they have a list of hospitals they typically attempt first and go down the line when trying to find placement. E#1 stated that typically the other hospital will tell us who is the accepting physician and this is usually arranged with conversations with the other hospital's crisis/central access team. E#1 stated that E#1 did not reach out to anyone at Hospital B before sending Pt. #1 there. E#1 stated that after sending Pt. #1 to Hospital B, they received a call from their ED staff at Hospital B asking why the patient was sent to them. E#1 stated that Hospital B stated that they didn't have inpatient psychiatric services. E#1 stated that this was the first time E#1 had a patient that was an active duty police officer, and didn't know what their protocols were. E#1 stated that in all other instances E#1 has reached out to the recipient facility to ensure they accepted the patient and had the capabilities to treat the patient before sending them. E#1 stated that E#1 admits that it was an EMTALA violation.

6. An interview was conducted with the ED Medical Director (MD#2) on 06/05/2025, at approximately 9:00 AM. MD#2 stated that MD#2 was made aware of the case with Pt .#1 the day after it occurred. MD#2 stated that they discussed the missed opportunity to communicate with the other facility. MD#2 stated that it should be a collaborative effort between the provider, nursing, and central access to ensure that a transfer is appropriately arranged.

B. Based on document review and interview, it was determined that for 1 of 5 behavioral health patient (Pt. #1) transfer records reviewed, Hospital A failed to ensure that the physician completed a written certification for transfer, including the reason for transfer and the risks and benefits associated with the transfer.

Findings include:

1. Hospital A's policy titled, "MW [Midwest] Region EMTALA (Emergency Medical Treatment and Labor Act)" (revised 12/09/2024), was reviewed and required, " ...patient may be transferred if hospital staff provide stabilizing treatment for the patient's EMC [emergency medical condition] within the Capacity and Capabilities of the Hospital and sections a-d below are met: ....a) A physician certifies the Transfer, or the Transfer occurs upon the request of the patient or a legally responsible person acting on the patient's behalf, as documented on the Patient Transfer Form... (1) Transfer with Certification: A physician must certify that the medical benefits expected from Transfer outweigh the risks and describe the reasons for and potential risks and benefits of the Transfer by completing the applicable areas on the Patient Transfer Form..."

2. Hospital A's clinical record of Pt. #1's ED visit on 04/18/2025 was reviewed on 06/03/2025. Pt. #1 presented to the ED on 04/18/2025 at 3:12 PM with a chief complaint of suicidal ideation/SI.

- The Triage Note, dated 04/18/2025 at 3:37 PM included "[Pt. #1] arrived ambulatory through triage with c/o [complaint of] suicidal ideation, with plans to use service weapon. No hx [history] of SI ... Accompanied by fellow officers."

- The Medical Screening Examination/MSE completed by ED Physician (MD#1) on 04/18/202 at 4:35 PM, included "...Patient presents to the emergency room with suicidal ideations. Patient has access to weapons. No acute medical complaints at this time, routine lab work shows no acute medical issues. No indication for any further medical workup at this time. Central access as well as the fellow officers have arranged for inpatient treatment. Patient to be transferred with a certificate via ambulance."

- The Central Access Licensed Clinical Professional Counselor/LCPC (E#1) note, dated 04/18/2025 at 7:02 PM, included "Patient in need of transfer due to on-site BH [behavioral health] unit - no appropriate bed [Hospital Bed Report dated 04/18/2025 indicated the BH units were not at capacity, see interview with E#1 for reason for transfer]. Patient Site Preference 1) [Hospital B] ... EAP [Pt. #1's Employer's Employee Assistance Program] Team Lead [Z#1] requested patient be sent to this facility as this is a facility they use for active duty police, [Z#1 stated that they] called and confirmed patient can be sent there without referral packet being done or RN to RN. PCS (Physician Certification Statement) form completed and placed on chart, called [Ambulance Service] ... scheduled BLS [basic life support] transport."

- Another note by E#1, dated 04/18/2025 at 7:11 PM, included "[Pt. #1] presenting to the emergency room with [Pt. #1's] EAP support team after calling their crisis line and endorsing having suicidal thoughts with a plan to use service gun. Patient was medically cleared and central access evaluated patient. Patient gave consent for EAP team to be in assessment as well as Peer support officer. Also gave verbal consent to provide information to friend at bedside ... Patient reports today everything came to a head, [Pt. #1] reports being in a 'dark place' and stated [Pt. #1] sat with [Pt. #1's] gun in front of [Pt. #1] on bed for a couple hours and eventually called the EAP crisis line. Patient stated prior to today, [Pt. #1] never had suicidal thoughts that were active, only passive death wishes when going through separation and random other points in [Pt. #1's] life. Patient has never attempted suicide, reports unknown mental health history in family. Patient reports reasons to live are daughter. [Pt. #1] reports knowing the impending death of mother from cancer is hard, [Pt. #1] reports great support around [Pt. #1] with EAP and police coworkers ... Above contacts at bedside during whole assessment and vouched for patient's safety. Informed writer [Pt. #1] will be with someone at all times and escorted to the facility, informed writer they took [Pt. #1's] gun and have it secured. EAP reports the facility [Hospital B] patient is transfer[ing] to is the facility they use in these situations, the reason [Pt. #1] came to [this] ED was 'lack of knowledge' [by the officers who brought Pt. #1 here] and usually they transport people in patient's situation directly to the facility [Hospital B] but stated there were many cops at [Pt. #1's] home and [Pt. #1's child] was witnessing this and they felt best situation was to take [Pt. #1] to [this] ED. Informed above [Pt. #1] will need to go via ambulance per protocol as the above mentioned taking [Pt. #1] would be a discharge and it is not safe nor protocol with a suicidal patient, above named all in agreement with ambulance transport and thankful for the help provided in making sure patient is taken care of ... Pt does meet criteria for psychiatric inpatient hospitalization as evidenced by SI with a plan to shoot self with service gun. ED attending notified of treatment plan and is in agreement ... Involuntary petition and certificate were completed ..."

- The record lacked documentation that any contact with Hospital B was made regarding acceptance of transfer of Pt. #1 and/or capacity/capability.

- A Nurse's (E#2) note, dated 04/18/2025 at 7:21 PM, included "Per [E#1] (central access) no report necessary to [Hospital B]. [Ambulance] here - given PCS and face sheet; awaiting belongings."

- Nursing Discharge Note, dated 04/18/2025 at 7:39 PM, included "Patient discharged in the care of ambulance. Transfer charge completed by [E#2]. Patient vitals stable upon transfer. Public Safety has returned personal belongings to patient and they are in the care of [Ambulance Service] for transport. Patient stable upon discharge."

Hospital A's record lacked the physician's written certification for transfer form, including the risks and benefits of transfer, for Pt. #1.

3. Hospital B's clinical record of Pt. #1's ED visit on 04/18/2025 was reviewed on 06/05/2025.
Pt. #1 presented to Hospital B's ED by ambulance on 04/18/2025 at 9:22 PM with a chief complaint of suicidal ideation.
-ED Triage Note, dated 04/18/2025 at 9:25 PM, included "Pt arrived to the ED from ambulance with complaints of suicidal ideation. Pt is a [police] officer and wanted to shoot self with service weapon. Pt came here from [Hospital A] with no notice of pt coming here. Pt was an involuntary petition in IL (Illinois), pt is voluntary here at this time. Pt is A&O [alert and oriented] x4 and appears to be in no distress."

4. An interview was conducted with the ED Medical Director (MD#2) on 06/05/2025, at approximately 9:00 AM. MD#2 stated that it should be a collaborative effort between the provider, nursing, and central access to ensure that a transfer is appropriately arranged. MD#2 stated that they are working on education for the staff to ensure that transfer forms are being completed, contain all the necessary components (i.e. accepting facility), and are included in the patient's medical record.