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Based on interview, medical record reviews, and hospital policy and procedures, bed census reports, on-call schedules and Assessment and Referral forms, the participating hospital hospital with psychiatric capabilities failed to accept the request for a transfer of a patient requiring psychiatric services from another participating hospital that did not provide these services. (Patient #1)


The findings include:

Cross reference A 2411: The participating hospital with psychiatric capabilities failed to accept the request for a transfer of a patient requiring psychiatric services from another participating hospital that did not provide these services. (Patient #1)

Based on interviews, medical record reviews, hospital policies and procedures, census reports, on call schedules, assessment and referral forms, and other written data and materials, the participating hospital with psychiatric capabilities failed to accept the request for a transfer of a patient requiring psychiatric services from another participating hospital that did not provide these services. (Patient #1)


The findings are:


Review of Hospital C's (Palmetto Health Richland)Policy, titled, "Emergency Care/EMTALA", effective March 5, 1998, Revised December 1, 2011 was reviewed. The section titled, "PROCEDURES STEPS, GUIDELINES, RULES, OR REFERENCE;....8. Palmetto shall not refuse to accept an appropriate transfer of an individual requiring specialized capabilities or facilities available at Palmetto Health."

Review of Hospital C's (Palmetto health Richland) policy, titled, "Admission Criteria-Adult Behavioral Care Services, reads, "Policy Statement- It is the policy of the Adult Behavioral Care units to admit medically stable adults 18 years of age and older who have psychiatric needs. Patients must be able to participate in and benefit from the structured, therapeutic environment....Admission Criteria Adult Behavioral Care...1. General Inclusionary Criteria: Patients who are an acute danger to self and /or others as a result of mental illness. ...2. Inclusionary Criteria for RS-1 and RS-2(Crisis Stabilization Units) 2.1 Patients who require a higher level of observation due to the intensity of their illness or the potential for disruptive behavior during their hospital stay. 2.2 Patients who may require use of seclusion and /or restraint during their hospital stay. 2.3. Patients for whom severe psychotic symptoms are the primary presenting problem. 3. Inclusionary Criteria for RS-3( Transitions) 3.1. Patients who may be unable to participate in cognitive forms of therapy, but do not require a higher level of monitoring. 3.2 Patients who would be expected to have only brief episodes of disruptive behavior, which would be expected to respond quickly to staff interventions. 3.3 Patients who are appropriate for RS-4 programming may be admitted to RS-3 when there is limited availability on RS-4. 4. Inclusionary Criteria for RS-4 and 5th Averyt (Dual Diagnosis and Affective unit Respectively.) 4.1 Patient is able to engage in and benefit from cognitive forms of therapy 4.2 Recognizes body space boundaries. 4.3 Patient is able to clearly sustain good impulse control. 5. Inclusionary Criteria for RS-4 (Dual Diagnosis) 5.1 Patients admitted due to another psychiatric condition for which chemical dependency is a significant co-morbidity....5.4 Patients without chemical dependency issues who otherwise meet criteria for admission to RS-4 can be admitted if transfer to th Averyt is not feasible. The admitting physician will make this determination. 5.5 Mentally ill patients who require evaluation and/or treatment will be admitted in accordance with the admission criteria and all applicable laws of the State. 6. Exclusionary Criteria....6.5 Patients whose primary diagnosis is not a known or suspected DSM-IV Axis 1 condition...".
Review of Hospital policy, titled, Assessment Guidelines, reads, "...2. A clinical Assessment Screening Sheet should be completed for every call from a clinician. Information obtained will include demographics, psychiatric and chemical dependence issues, as well as medications and medical needs..".

Patient #1's chart from Hospital A (Transferring Hospital) was reviewed. Review of the "Physician Chart" dated 3/5/2012 at 1131 a.m. indicated that Patient #1 presented to the Emergency Department accompanied by Law enforcement with complaints of "Psych (psychiatric) Problem". The Telepsychiatry Consult Forms (TCF) were reviewed. The TCF dated 5/5/2012, section titled, "ED's Perception of Problem" specified in part,"Records indicate that pt (patient) comes to ED as a result of homicidal ideations(HI), where he had conflict with a resident .... PT had recent HI as a result and asked for help.... Reason for consult. Danger to others....Target symptoms for treatment "Depression....HI ideation attempts....History of Present Illness..Pt is a 21 year old male who came to the ED having HI... pt still states, "Im going to kill him"...Mental Status Examination.. Thought Content Hallucinations... yes...Homicidal Ideation ...yes... Violence Risk appraisal ...Has thoughts of killing resident...prior attempts of assaultive behavior.. in my clinical opinion still at risk for violent behavior... Says he does have AH (auditory hallucinations)... Explanation of mood instability - anger and depression. Recommendation... voluntary agree to admission." Review of TCF dated 3/12/2012, specified in part, "He (Patient #1) still has active thoughts about killing him (resident ) today and now. He has no thoughts of killing himself. He hears voices and people calling his name. Says he was diagnosed with bipolar disorder in the past but has not been in any treatment in the recent past. He has not been able to afford any of his medications in a year. He is upset and frustrated that he had not been admitted to a facility yet but knows that the staff is looking for a bed... In my opinion this patient is still at risk for violent behavior...Explanations of diagnosis/thoughts with the previous... for admission. I would convert this to Involuntary at this time as he is getting anxious may want to leave and is still actively Homicidal... Recommendations: Involuntary. (Involuntary commitment purpose to get proper medical assistance for a person who has become danger to himself or others due to mental illness)". Review of the TCF dated 3/12/2102 at 13:48 (1:48 p.m.) the section titled "Violent Risk Appraisal" specified in part, 'Main informant is, (Patient)...Main informant reports these assaultive thoughts: He wanted to kill another patient (resident at community home) ... Main informant reports these assaultive plans: Was carrying an axe around facility (community home) while making threats. Main Informant reports assaultive intent of: High: Still has active thoughts of killing this person... In my clinical opinion, this patient is, still at risk for violence." Part II of the Certificate of Licensed Physician Examination for Emergency Admission dated 3/5/2012 at 11:31 a.m., 3/09/2012 at 6:50 a.m., 3/13/2012 at 9:25 a.m. and 3/16/2012 at 9:15 a.m. for Patient #1 were reviewed. The Physician documented in part, "I, the undersigned LICENSED PHYSICIAN, have examined the above named person (Patient #1) and am of the opinion that the said individual ... is MENTALLY ILL AND because of this mental condition CURRENTLY POSES A SUBSTANTIAL RISK of physical harm to self and/ other to the extent that INVOLUNTARY EMERGENCY HOSPITALIZATION is recommended.... My recommendation for INVOLUNTARY EMERGENCY HOSPITALIZATION is based on the following symptoms and specific examples of behavior which indicate mental illness and probable risk of harm: Homicidal ideation is a danger to self and others."

Review of the Master of Social Worker(MSW) notes from Hospital C's Assessment and Referral Center (a form used by Hospital C to determine if a patient is approved for Behavioral Health Services) dated 3/8/12, reads, " .... homeless/self pay/ "has a mom" but unsure of why he can't live w (with) her/violent/homicidal [sic] threats towards others; unknown/reported drug use". On 3/8/2012, a second note was recorded by the MSW (Hospital C) that reads, " ....MSW (Master Social Worker) received a call from Director stating that Mr. ...., (VP Psychiatry) had received a call from Hospital A and was informed that this pt. (patient) remains homicidal, violent verbal altercation w/a threat to kill a person that he got in a disagreement w/at the local homeless shelter; unknown hx (history) of Depression (questionable hx of Depression per ...., we just don't know") and unknown hx of MI (Mental illness) due to pt. from "New Jersey" and have not given their ER staff any information; stated he has been in their ER for approx (approximately) 4 days and he continue to state that is D/C (discharged) he was going to "kill" this person at the shelter-- no reported Psychoses and no reported S/S (signs and symptoms) of Depression or drug use-- Spoke w/ Dr.(Psychiatrist at Hospital C) .... and pt appears not appropriate for psych. Admission to R/S due to no hx. of MI (Mental Illness), no meds (medications) and no current psychoses-- (Hospital A Staff) appeared unhappy w/this disposition, asked writer several questions, gave her the name of several hospitals, and (Hospital A Staff) stated, "we have called all those places , it just seems like you didn't want to take him cause he didn't have insurance; explained the process again and informed that's just one of the question we asked, it doesn't determine admission to R/S--- If we have an appropriate bed, we call the MD (Medical Doctor) on call, and the MD makes the final disposition."

A review of Hospital C's Psychiatric Census submitted by the Director of Regulatory Compliance for the dates of 03-03-12 through 03-17-12 revealed that on 03-08-12, the total census of the psychiatric units was 31 patients. The confirmed capacity of the Psychiatric Unit is 52 beds: R/S Unit 1 and 2 are the Crisis Stabilization Units and had a patient census of 11 and 7 patients respectively, R/S -3: the Transitional Unit had 6 patients, and R/S- 4 had 7 patients. The R/S Unit- 1 had 10 patients, R/S Unit -2 had 6 patients, R/S Unit-3 had 9 patients, and R/S Unit-4 had 6 patients. The hospital had the capacity to provide care for Patient #1 when requested for transfer on 3/8/2012. Review of Hospital C's Psychiatry Call schedule dated March 8, 2012 verified that a Psychiatrist was on call. The hospital had the capability to provide care to Patient #1 when requested for transfer on 3/8/2012. Hospital C failed to accept an appropriate transfer that was within the capability and capacity of the hospital when requested by Hospital A for Patient #1 on 3/8/2012.

On 3/15/12, Registered Nurse (RN)#1 who was employed by Hospital A (Transferring Hospital), reported, "we have a patient at this hospital that was sent here by Facility B (mental health clinic) because he/she got angry at his place of residence(community home) and "tried to kill" another one of the residents. The staff (community home) was able to break things up, and he/she was sent to Facility B (mental health clinic) for evaluation. Facility B (mental health clinic), in turn, had the police to bring the patient to our hospital (Hospital A - Transferring Hospital)). We called Hospital C for a psychiatric bed, and we were told they did not have any beds. We called and talked with the Vice President of Psychiatry at Hospital C who assured me that the hospital did indeed have beds, and he/she would have someone from admissions to call me back. (As verified by review of Hospital C's Bed Census Report dated 3/3/2012 - 3/17/2012). Mental Health Worker #1 (Hospital C) from his/her team did call back, and said they did not have any beds. When I told him/her(mental health Worker #1 - Hospital C) that I had talked to the Vice President of Psychiatry, and the Vice President of Psychiatry assured me they did have beds, Mental Health Worker #1(Hospital C) explained that the hospital (Hospital C) did not have a bed for "him" since the patient did not meet their criteria. All of their beds, including their Transition beds require that the patient be "Psychotic", and they said, "this patient is not Psychotic". We (Hospital A) have performed tele-psych on this patient in our Emergency Room. The latest consult with them was on 03-12-12, and they noted " in my clinical opinion, this patient is still at risk of violent behavior"."

On 03-21-12 at 1330, an interview was conducted with the Vice President (VP) of Psychiatry at Hospital C. During the interview, the Vice President of Psychiatry requested to be accompanied by the Director of Regulatory Compliance. The Vice President of Psychiatry reported that he/she had a remote memory of the conversation with Registered Nurse #1 (Hospital A), but wasn't sure which hospital it was, but he/she thought it might be a hospital that started with a "C". The Vice President of Psychiatry reported that that the hospital in question had contacted the office of referral and assessment staff but hadn't had any luck placing the patient. The Vice President of Psychiatry reported that Hospital A had beds by the look at the hospital census so he/she contacted the Director of Assessment and Referrals. The Vice President of Psychiatry reported that he/she had not followed up with the Director of Assessment , but he/she had not received any more calls from the other hospital either. The Vice President of Psychiatry stated, "We get patients from all over the state". The VP of Psychiatry explained the Assessment Intake staff will gather information to present to the psychiatrist who can admit the patient, or direct to another facility, or refer to other resources. The VP of Psychiatry reported staff ask for patient financial information on assessment, but we take no payor source. He/She verified Hospital C has 2 Adult Acute units, a Dual Diagnosis Unit and a Step Down Unit. The VP of Psychiatry reported "I did get a call from the CFO (Chief Financial Officer) two days later from whatever hospital. If the hospital had a bed, the patient should of been admitted. The facility failed to ensure that the hospital accepted an appropriate transfer of Patient 31 on 3/8/2012 as the individual required the specialized psychiatric capability and capacity that was available on 3/8/2012 at Hospital C.

On 03-21-12 at 1420 an interview with the Director of Assessment and Referral Center who was accompanied by the Director of Regulatory Compliance revealed that clinicians consisting of Social Workers and a Registered Nurse from the Assessment and Referral Center receive clinical information to determine where patients should be placed. They have bed availability for psychiatric beds at Hospital C and sister Hospital D. If it looks like the client would benefit from hospitalization, the clinician would do a full assessment, and at that point, give it to a psychiatrist. The clinician also considers the length of stay that the client already has had at the other facility. The Director explained that Hospital C is a short term hospital and some facilities are looking for long term programs. If the person was too violent, that might be left up to the physician to consider what that would do to the patients admitted in the psychiatric unit. The Director reported that he/she was aware of a hospital that had called the VP of Psychiatry that needed psychiatric follow up. He/She reported "the patient was very assaultive, transient, passing through their Emergency Department. The Director stated that the hospital couldn't give much history on the patient. The Director reported, "We don't always talk to trained staff. Typically the Assessment Clinician would be talking to the ED nurse or Social Worker, and not necessarily to the physician." The Director reported that he/she knew the psychiatrist was presented with the information on this case and declined admission. The Director stated, "We can only present clinical information and its the decision of the psychiatrist."

On 03-22-12 at 1100, an interview with the Psychiatric Hospitalist, who was accompanied by the Director of Regulatory Compliance. The Psychiatric Hospitalist verified that he/she was on call for the Assessment and Referral Department on 03-08-12. The Psychiatric Hospitalist explained that if a hospital calls looking for placement, the Assessment and Referral Center conduct their assessment of the patient. Then the Assessment and Referral Center pages whoever is on call and presents their assessment of the patient to the psychiatrist on call. The psychiatrist either accepts or denies the admission, and then the Assessment Team will do the leg work. The Assessment Team informs the facility if the patient was accepted or not. If the patient was accepted, the Assessment Team makes the bed arrangements. The Psychiatric Hospitalist explained that he/she couldn't list all the criteria for admission without the hospital policy in front of him/her, but mostly, the patient would have to be having active psychosis like depression and being a danger to self or others. The patient would have to be ambulatory with very minor medical problems. In other words, the patient has to be medically stable and have an Axis 1 disorder. Hospital C's psychiatric units consist of a Crisis Stabilization Unit where the patient is actively psychotic and can attend programming, and a Transitional unit where the patient can be psychotic. The Psychiatric Hospitalist reviewed the assessment intake report for Patient #1, and explained that the referring hospital couldn't give any signs or symptoms of Psychosis. The Psychiatric Hospitalist stated, "the psychiatrist is looking at current symptoms, and if it was an insurance issue, we wouldn't have any patients in the hospital."

On 03-21-12 at 1050, an interview was conducted with Mental Health Worker#1 at Hospital C. Mental Health Worker #1 reported that he/she could not recall any telephone call where he/she conveyed this type of information to anyone about a patient transfer. Mental health Worker #1 verified that he/she is employed in Hospital C's Assessment and Referral office. Mental Health Worker #1 reported that the purpose of the office for Referral and Assessment is to determine if the patient is appropriate for Behavioral Health Services. Mental Health Worker #1 stated, "patients with a psychiatric complaint or need are assessed either 1:1 or over the telephone to determine if the patient is appropriate for Behavioral Health services. The Referral Office gets many calls from different sources: other facilities, patients, and/or families for someone else. The Referral Office makes appointments for 1:1 assessments, or if the patient needs a referral to another facility. Mental Health Worker #1 explained that other hospital Emergency Rooms could contact th referral office for admissions to the Behavioral Health Units throughout the business day. He/She stated the Assessment and Referral office gets many calls from different hospitals, and the office tracks the psychiatric bed status throughout the day.

Each of the Psychiatric units have their own criteria. When hospitals call for a transfer, office staff request information such as the the client's name, insurance, clinical information, age, and then, staff looks to see if a bed is available. If the patient is determined to meet criteria, then staff tell them there is a bed available based on what little information we receive. If different people from the same facility call about the same patient and give different clinical information, which happens, then we might need medical records before giving bed availability. If someone calls, the procedure is to request standard information and based on what information we receive, staff tell us if we do/don't have a bed. Typically what happens is a call is received, we intake the information. If a bed available, then staff conduct a full assessment, and then, staff contacts the psychiatrist on call. The psychiatrist on call makes the final decision for bed placement and admission. The Office of Assessment and Referral only makes recommendations". On 03-23-12 at 3:30 p.m., another telephone interview was conducted with Mental Health Worker #1 who revealed, "the first encounter with the referral information obtained from Hospital A on 03-08-12 did not lead to a physician review because not enough clinical information was obtained from staff at Hospital A about the patient. I referred her (Staff at Hospital A) to a facility closer to their (Hospital A) location. The same day, I called back, and asked the staff psychiatric many questions such as what is currently going on, and then, I asked questions about substance abuse, but they (staff) said no drug use. If there was more clinical information like vital signs, meds, signs and symptoms, I would have done a full assessment of the patient. The psychiatrists want to know a patient's psychiatric history, and in this case, they (Hospital A) couldn't give me any. You can be homicidal for legal reasons, but they couldn't give me any signs or symptoms of a Psychosis or of a Mental Health history. The Psychiatric Hospitalist started questioning me. I could only tell the doctor what they (staff) told me. I couldn't answer any questions from the doctor. Everything the Psychiatric Hospitalist asked me was either a "no or I don't know". If doctors can't take the client, I try to be helpful and try to give them referrals to other hospitals that they can go to. The referral source wasn't happy." The hospital failed to ensure that their "Emergency care/EMTALA" policy and procedure was followed as evidenced by refusing to accept Patient #1 on 3/8/2012, an appropriate transfer who required psychiatric specialized capabilities or facilities that were available at Palmetto Health Richland.