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.

HARLAN ARH HOSPITAL 81 BALL PARK ROAD HARLAN, KY 40831 June 21, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interviews, record reviews, and review of facility policies, it was determined the facility (Facility #1) failed to provide a medical screening and appropriately transfer one (1) of twenty (20) patients (Patient #1, an adolescent). On 05/27/17, Patient #1 presented to the Emergency Department (ED) of Facility #1 with his/her mother with cuts to the wrist and suicidal ideation. Registered Nurse (RN) #1 told Patient #1's family during triage that the facility did not treat adolescents with a psychiatric condition and Patient #1's mother requested transfer to Facility #2. During triage, RN #1 assessed that the patient had suicidal ideation, intent, a plan, and access to "lethal means." According to the assessment, Patient #1's suicide risk was "moderate" and the patient was placed on suicide precautions. Advanced Practice Registered Nurse (APRN) #1 assessed Patient #1 and determined the patient had Suicidal Thoughts, Depressive Disorder, and Superficial Self-Inflicted Cut to left wrist; however, there was no evidence a "psychiatric screening" was conducted as required by the facility's policy to determine whether an emergency medical condition existed. The facility attempted to arrange a transfer to Facility #2; however, Facility #2 did not send requested paperwork to Facility #1. In the meantime, APRN #1 discharged Patient #1 with the patient's mother and grandfather to have them transport Patient #1 to Facility #2 (a facility sixty-nine (69) miles away) and did not arrange the transfer of the patient to ensure the patient's safety. Patient #1's family transported the patient to Facility #2 in their private vehicle and Facility #2 admitted Patient #1 on 05/27/17 for treatment of Depressive Disorder and Suicidal Ideation.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on interview, record review, and review of facility policies, it was determined the facility (Facility #1) failed to provide an appropriate medical screening for one (1) of twenty (20) patients (Patient #1). Patient #1 presented to the Emergency Department (ED) on 05/27/17, with cuts to the wrist and suicidal ideation. Advanced Practice Registered Nurse (APRN) #1 conducted a medical screening; however, there was no evidence a "psychiatric screening" was conducted as required by the facility's policy, to determine whether an emergency medical condition existed. APRN #1 determined Patient #1 was stable and discharged Patient #1 with the understanding that the patient's mother would transport Patient #1 to Facility #2 for treatment of the patient's psychiatric condition. Patient #1's family transported the patient to Facility #2 in their private vehicle and Facility #2 admitted Patient #2 on 05/27/17 for treatment of Depressive Disorder and Suicidal Ideation.

The findings include:

Review of the facility's policy titled "EMTALA-Medical Screening," reviewed 10/14/08, revealed the facility defined a medical screening exam and the "process required to reach, with reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition exists." The policy stated that such screening must be completed within the facility's capability and available personnel, to include on-call physicians. The medical screening exam is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred. The policy stated the screening was required to be conducted to the extent necessary "to determine whether an emergency medical condition exists with respect to a psychiatric patient, a medical screening consists of both a medical screening examination and a psychiatric screening."

Review of the credentialing file for Physician #1 and APRN #1 revealed no documented evidence the facility oriented/educated the providers on the facility's EMTALA policies and no evidence the providers had psychiatric education/certification.

Interview with the ED Director on 06/20/17 at 2:15 PM revealed when a patient presented to the ED with a psychiatric diagnosis, staff from the behavioral health unit were required to conduct a psychiatric screening for the patient; however, behavioral health staff only screened adult patients and the facility did not have a procedure in place to screen adolescent patients as required per the facility's policy.

Review of the medical record for Patient #1 revealed Patient #1 arrived at the facility on 05/27/17 at 5:25 PM and Patient #1 was triaged at 6:24 PM for suicidal thoughts. Registered Nurse (RN) #1 documented during the triage assessment that Patient #1 had complained of suicidal ideation for one (1) day. Patient #1 cut himself/herself with a razor on the left wrist and had several superficial lacerations on the left wrist. Patient #1 complained of anxiety and depression. Patient #1 stated he/she was not sure why he/she was suicidal and felt depressed and suicidal "sometimes." RN #1 documented on the Suicide Risk Assessment that "Patient #1 expressed thoughts of harming self/others." According to the assessment, the patient had suicidal ideation, intent, a plan, and access to "lethal means." According to the assessment, Patient #1's suicide risk was "moderate" and the patient was placed on suicide precautions.

Continued review of Patient #1's medical record revealed APRN #1 started an exam of Patient #1 on 05/27/17 at 6:53 PM. APRN #1 documented that she reviewed and agreed with RN #1's assessment. The APRN stated the patient presented with symptoms of depression and had "definite suicidal thoughts and has a plan." However, APRN #1 documented under the "psychiatric" portion of the physical exam that Patient #1 had suicidal ideation; however, "on questioning patient does not have a concrete plan regarding suicide and is rather vague." According to the assessment, Patient #1 had a healing scar on the left lower arm and had superficial, self-inflicted cuts. APRN #1 diagnosed Patient #1 with Suicidal Thoughts, Depressive Disorder, and Superficial Self-Inflicted Cut to left wrist.

Continued review of the record revealed RN #2 documented on 05/27/17 at 7:02 PM that she contacted Facility #2, spoke with a staff member, and was having forms faxed from Facility #2 to Facility #1. RN #2 documented at 7:19 PM that the forms from Facility #2 had not been received.

Further review of Patient #1's medical record revealed APRN #1 documented at 8:48 PM that "Mom to take [Patient #1] to [Facility #2] tonight for suicidal thoughts." Physician #1 also documented at that time (8:48 PM on 05/27/17) that he had examined Patient #1, "conducted a "face-to-face encounter," and agreed with the "mid-level assessment" and plan of care.

According to Patient #1's medical record, the facility discharged Patient #1 on 05/27/17 at 9:00 PM with the patient's mother.

Review of Patient #1's medical record from Facility #2 revealed the patient presented at Facility #2's ED on 05/27/17 at 11:05 PM with a "Mental Health Disorder" and was diagnosed with Self-Mutilating Behavior and Suicidal Thoughts. Patient #1 was admitted to Facility #2 on 05/28/17 for treatment of Depressive Disorder and Suicidal Ideation. Patient #1 was discharged home on 05/30/17 with outpatient treatment planned.

An interview with Patient #1's family was attempted on 06/20/17 at 11:55 AM and 6:21 PM and on 06/21/17 at 10:50 AM without success.

Interview with RN #1 on 06/20/17 at 12:00 PM revealed he was the triage nurse on 05/27/17 when Patient #1 was brought into the ED for treatment of suicidal ideation. RN #1 stated he conducted the triage assessment for Patient #1 and found that he/she had several superficial cuts on the left wrist and that Patient #1 stated he/she was having suicidal thoughts. RN #1 stated he placed Patient #1 on suicide precautions (which is 1:1 care and the patient is searched for safety) and had no other contact with Patient #1. RN #1 stated he had specialized behavioral health training and often conducted psychiatric screenings for adults who presented to the ED with a psychiatric illness; however, RN #1 stated he was not trained to conduct a psychiatric screening for adolescents.

Interview with APRN #1 on 06/20/17 at 1:25 PM revealed the facility did not have the capability to assess/treat adolescents with psychiatric illness and she did not have any advanced education/certification in behavioral health; however, she stated she assessed Patient #1 on 05/27/17 for complaints of suicidal ideation. APRN #1 stated she discharged the patient because she felt the patient was stable and did not have a suicide plan. APRN #1 stated she discharged Patient #1 with the knowledge that the family was taking the patient to Facility #2.

Attempts to interview Physician #1 were unsuccessful; however, a review of Physician #1's statement to the facility dated 06/08/17 at 8:11 AM revealed he examined Patient #1 via "Intra net [electronic medical record]" (Physician #1's documentation stated he conducted a "face-to-face assessment) and agreed with APRN #1 to discharge Patient #1 so the patient's family could transport Patient #1 to Facility #2. The physician stated the steps were taken on the guardian's insistence that they take the patient to Facility #2 because they wanted to save time. Physician #1 stated, " ...we did not need to call them [Facility #2] as it might take few hours to complete the process."

Interview with the facility's Risk Manager on 06/20/17 at 10:15 AM revealed the facility recognized Patient #1 was not transferred per policy and the facility began educating staff regarding the facility's policy on EMTALA. Further interview with the Risk Manager and review of the facility's educational material revealed on 06/07/17, the facility re-educated all ED staff and on 06/08/17 all ED providers were educated. The facility also completed individualized education for Physician #1 and APRN #1 regarding the facility's EMTALA policy.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on interviews, record reviews, and review of facility policies, it was determined the facility (Facility #1) failed to appropriately transfer one (1) of twenty (20) patients (Patient #1, an adolescent) when Patient #1's family requested transfer to Facility #2. On 05/27/17, Patient #1 presented to the Emergency Department (ED) of Facility #1 with cuts to his/her wrist and suicidal ideation. Staff told Patient #1's family that the facility did not treat adolescents with a psychiatric condition and Patient #1's mother requested transfer to Facility #2. The facility attempted to arrange a transfer to Facility #2; however, Facility #2 did not send requested paperwork to Facility #1. Advanced Practice Registered Nurse (APRN) #1 then discharged Patient #1 to the care of his/her mother and grandfather to have them transport Patient #1 to Facility #2 (a facility sixty-nine (69) miles away) and did not arrange the transfer of the patient to ensure the patient's safety.

The findings include:

Review of the facility's policy titled "EMTALA-Transfer Policy," reviewed 10/14/08, revealed the facility was required to ensure that a patient that requested or required transfer for further medical care and follow-up in connection with treatment for an Emergency Medical Condition was transferred appropriately. Further review of the policy revealed any legally responsible person acting on the patient's behalf must first be fully informed of the risks of a transfer, the alternatives to transfer, and of the facility's obligations to provide further examination and treatment sufficient to stabilize the patient's Emergency Medical Condition. The policy stated that to provide an appropriate transfer the following was required: the transferring facility must within its capability provide treatment to minimize the risks to the health of the individual; the receiving facility must have available space and qualified personnel for the treatment of the individual and must have agreed to accept the transfer and provide appropriate treatment; and the transferring facility must send copies of all available medical records pertaining to the individual's emergency condition to the facility where the patient was being transferred.

Review of the credentialing file for Physician #1 on 06/20/17 at 2:00 PM revealed Physician #1 was appointed privileges on 07/07/15 and reappointed on 02/01/17; however, there was no documented evidence the facility oriented/educated Physician #1 on their EMTALA policies.

Review of the credentialing file for APRN #1 on 06/20/17 at 2:00 PM revealed APRN #1 was appointed privileges on 08/21/15 and reappointed on 02/01/17; however, there was no documented evidence the facility oriented/educated APRN #1 on their EMTALA policies.

Review of the medical record for Patient #1 revealed Patient #1 arrived at the facility on 05/27/17 at 5:25 PM and Patient #1 was triaged at 6:24 PM for suicidal thoughts. Registered Nurse (RN) #1 documented during the triage assessment that Patient #1 had complained of suicidal ideation for one (1) day. Patient #1 cut himself/herself with a razor on the left wrist and had several superficial lacerations on the left wrist. Patient #1 complained of anxiety and depression and felt depressed and suicidal "sometimes." RN #1 documented on the Suicide Risk Assessment that "Patient #1 expressed thoughts of harming self/others." According to the assessment, the patient had suicidal ideation, intent, a plan, and access to "lethal means." According to the assessment, Patient #1's suicide risk was "moderate" and the patient was placed on suicide precautions.

Continued review of the record revealed RN #2 documented on 05/27/17 at 7:02 PM that she contacted Facility #2 to arrange transfer, spoke with a staff member, and was having forms faxed from Facility #2 to Facility #1. RN #2 documented at 7:19 PM that the forms from Facility #2 had not been received.

However, a review of APRN #1's documentation revealed she did not arrange a transfer to Facility #2, but discharged Patient #1 on 05/27/17 at 8:48 PM to be transported by private vehicle by his/her mother and grandfather to Facility #2. Physician #1 also documented at 8:48 PM on 05/27/17 that he had seen and examined Patient #1 and agreed with APRN #1's recommendations and findings.

Interview with RN #1 on 06/20/17 at 12:00 PM revealed he was the triage nurse on 05/27/17 when Patient #1 was brought to the ED for treatment of suicidal ideation. RN #1 stated Patient #1's mother reported the patient was suicidal and she requested Patient #1 be admitted to the facility. RN #1 stated he informed Patient #1's mother that the facility did not treat adolescent psychiatric illness and the closest facility that treated adolescents was Facility #2. RN #1 stated he then conducted the triage assessment of Patient #1 and found that he/she had several superficial cuts to the left wrist. Patient #1 stated he/she was having suicidal thoughts, but did not tell him if he/she had a plan. RN #1 stated he placed Patient #1 on suicide precautions (which is one-on-one care and the patient is searched for safety). RN #1 stated that was the last contact he had with Patient #1.

Review of the "Behavioral Health Evaluations Patient Monitoring Record" dated 05/27/17 revealed Patient #1 was on suicide precautions and received one-to-one monitoring from 7:00 PM to 9:00 PM on 05/27/17 and the monitoring was provided by RN #2 from 7:00 PM until 8:00 PM.

Interview with RN #2 on 06/20/17 at 1:50 PM revealed she was Patient #1's nurse and contacted Facility #2 about admission to their psychiatric unit. She stated Facility #2 stated they would fax information to Facility #1 regarding the transfer; however, Facility #1 never received the paperwork. In the meantime, APRN #1 discharged Patient #1. RN #2 stated she was aware Patient #1's family was taking the patient to Facility #2 for treatment and normally when transferring a patient to another facility the patient was not discharged , but a transfer was initiated by the physician and documentation and report to the receiving facility was required.

Interview with APRN #1 on 06/20/17 at 1:25 PM revealed she did not have any advanced education/certification in behavioral health; however, she stated she assessed Patient #1 on 05/27/17 for complaints of suicidal ideation. APRN #1 stated she felt the patient was stable and did not have a suicide plan. She further stated the facility did not have the capability to assess/treat adolescents with psychiatric illness and planned to discharge the patient home to follow up with outpatient treatment; however, Patient #1's mother wanted the patient transferred to Facility #2 for treatment. APRN #1 stated she discharged Patient #1 with the knowledge that the family was taking the patient to Facility #2. APRN #1 stated she did not arrange a transfer for Patient #1 as requested by the patient's family.

An interview with Patient #1's family was attempted on 06/20/17 at 11:55 AM and 6:21 PM and on 06/21/17 at 10:50 AM without success.

Review of Patient #1's medical record from Facility #2 revealed the patient presented at Facility #2's ED on 05/27/17 at 11:05 PM with a "Mental Health Disorder" and was diagnosed with Self-Mutilating Behavior and Suicidal Thoughts. Patient #1 was admitted to Facility #2 on 05/28/17 for treatment of Depressive Disorder and Suicidal Ideation. Patient #1 was discharged home on 05/30/17 with outpatient treatment planned.

Interview with the facility's Risk Manager on 06/20/17 at 10:15 AM revealed the facility recognized Patient #1 was not transferred per the facility's policy and the facility began educating staff regarding the facility's policy on EMTALA. Further interview with the Risk Manager and review of the facility's educational material revealed on 06/07/17 the facility re-educated all ED staff, and on 06/08/17 all ED providers were educated. The facility also completed individualized education for Physician #1 and APRN #1 regarding the facility's EMTALA policy on 06/08/17.