Based on record review and staff interview it has been determined that the facility failed to ensure that a patient who needed further treatment, was transferred to another facility for continued care, for 1 of 25 sample patients (ID #23). Findings are as follows: Patient ID #23 was brought to the ED (emergency department) on 9/10/15 by local EMS (emergency medical services), after an alleged suicide attempt. The patient was found in his college dormitory with a plastic bag around his head and scissors to his throat. The patient's medical record reveals, his/her mother states the patient had voiced SI (suicidal ideation) to her on the phone that evening. An MSE (medical screening examination) was completed by the ED physician, which revealed the patient was depressed and has had thoughts of ending his/her life. The ED physician determined that the patient was stable, and ordered the patient to be discharged to his/her parents. The discharge diagonsis was "Suicidal Ideation." Discharge instructions revealed the patient was told to go directly to another acute care hospital for continued care. The patient was transported to another acute care hospital in the car with his/her parents, and was Emergently Certified and transferred to another acute care hospital for an inpatient psychiatric admission. During a phone interview on 9/28/15 at approximately 9:30 AM, the ED physician who discharged the patient revealed, Discharge Instructions were for the patient to go directly to another acute care hospital for further care.

Based on record review and staff interview it has been determined that the facility failed to ensure that when a patient is transferred to another hospital, the receiving hospital is contacted and agreed to accept transfer of the patient. Additionally, the facility failed to send to the receiving facility all medical records (or copies thereof) related to the emergency condition, for 1 of 25 relevant sample patients (ID #23). Findings are as follows: Patient ID #23 was brought to the ED (emergency department) on 9/10/15 by local EMS (emergency medical services), after an alleged suicide attempt. The patient was found in his college dormitory with a plastic bag around his head and scissors to his throat. The patient's medical record reveals, his/her mother states the patient had voiced SI (suicidal ideation) to her on the phone that evening. The medical record reveals a "Suicide Ideation Screening" was completed, in which the patient answered "yes" to questions about feeling depressed or hopeless, having thoughts that life was not worth living, and thoughts of ending his/her life. Although the ED physician determined the patient was stable, he ordered the patient to be discharged to his parents. The discharge diagonsis was "Suicidal Ideation." Discharge instructions revealed the patient was told to go directly to another acute care hospital for continued care. The patient went to another acute care hospital and was Emergently Certified and transferred to another local hospital for an inpatient psychiatric admission. A call to the State Agency from the receiving hospital revealed the patient arrived at the facility without a notice from the sending hospital. The patient arrived at the facility without any medical records related to the patient's emergency condition, preliminary diagnosis or treatment provided. During a phone interview on 9/28/15 at approximately 9:30 AM, the ED physician who discharged the patient revealed, Discharge Instructions were for the patient to go directly to another acute care hospital for further care.