HospitalInspections.org

NOT CORRECTED

Based on interviews, reviews of medical records, hospital policy and procedures, bed census reports, on-call schedules and the hospital's assessment and referral form, 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 #7)


The findings include:


Cross Reference to 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 #7)

On the days of the Revisit Survey based on record reviews and interviews, the hospital failed to maintain a central log on each individual who presents to the emergency department seeking assistance and whether he/she refused treatment, was refused treatment, or whether he/she was transferred, admitted and treated, stabilized and transferred, or discharged for 10 randomly sampled individuals on the emergency department log.


The findings are:


On 1/11/13, Hospital A submitted an emergency department electronic form dated 1/10/13 through 1/13/13 that had headings labeled: Arrival Date & Time, Financial Number, Person Name - Full, Encounter Type, Birth Date, Age, MRN (Medical Record Number), Triage, MD (Medical Doctor) Exam, Chief C/O (complaint), Depart Date & Time, and Discharge Disposition. There are thirty - two (32) patient names listed on the emergency department form. Ten (10) of the thirty - two (32) patients had no discharge disposition recorded in the Discharge Disposition section of the emergency department log.

The facility failed to maintain a central log for 10 randomly sampled individuals who came to the
emergency department seeking assistance and, whether the individuals were refused treatment, or were
treated, admitted, stabilized, transferred or discharged.

NOT CORRECTED
Based on interview(s), review of medical records, hospital policy and procedures, bed census reports, on-call schedules, assessment and referral forms and emergency room logs, the participating hospital with psychiatric capabilities failed to accept the request for a transfer of a patient with an identified psychiatric emergency medical condition requiring psychiatric services from another participating hospital that did not provide these services. (Patient #7)


The findings are:


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...".

On 1/10/13 at 1100, review of the participating hospital with psychiatric capabilities (Hospital A- Palmetto Richland) transfer log, "Assessment and Referral EMTALA Log and Audit Sheet", dated 1/09/13 through 1/10/13, revealed Patient #7 was referred for admission from Hospital B (acute care hospital) for mental health issues. Review of Hospital A's assessment and referral log revealed Patient #7 was refused transfer by the on - call Psychiatrist at Hospital A. The Assessment and Referral EMTALA Log and Audit Sheet log had documentation that stated, "Reason for Refusal - Not SI (suicidal ideation)/HI (homicidal ideation) behavioral related to special needs not MI (Mental Illness)".

Review of Hospital A's referral and assessment form showed Patient #7's medical record was requested by Hospital A on 1/9/13 at 1320 from Hospital B, the hospital requesting a transfer for a psychiatric bed. Review of Patient #7's medical record forwarded to Hospital A by Hospital B revealed a facesheet in the medical record packet with the patient's payor source which was documented as Medicaid.
Review of Patient #7's emergency room medical record received from Hospital B revealed Patient #7 presented at Hospital B's Emergency Room on 1/7/13 at 1825. The medical record packet contained a form, titled, "Emergency Physician Record Psych Disorder, Suicide Attempt, Overdose", showed Patient #7 is a 20 year old male whose chief complaint was agitation. In the section labeled, "associated symptoms", the physician circled angry, frustrated, agitation, and hostile. The physician documented the patient's medical history as Asperger, (Asperger's syndrome - is a condition that is related to Autism), Autism, and Attention Deficit Disorder. Medications were listed as Adderall XR, Seroquel, Ativan, Valium, Haldol, Benadryl, Motrin, and Vistaril. The emergency physician ordered drug screens, urine screen, Basic Metabolic Panel, and a telemedicine consult with the reason for consult listed as "danger to others."
On 1/7/13 at 2334, documentation in Patient #7's medical record packet showed a telemedicine evaluation was conducted for the patient that revealed recommendations for "Psychiatric/substance abuse hospitalization indicated, involuntary white papers for safety....". Review of the telemedicine consult dated 1/07/13 revealed documentation in the section labeled "ED's (Emergency Department) perception of Problem" that showed the patient was brought to the ED after he got upset with his family today resulting in police involvement. .... Pt. (Patient) Has been appropriate in ED but mother is concerned due to events of today and recently. Pt. put a hole in the wall at home today, also did some other damage. Last week, he reportedly pulled knives out, was somewhat threatening toward stepfather, who he refers to as "Overseer" at times. ...". Review of the section labeled "History of Present Illness" revealed "...Pt. has been having increased mood & (and) behavioral problems recently. Pt spoke 1st (first), said, ...." I'm the one that's been suffering." In the section labeled "Violent Risk Appraisal", the telemedicine physician charted, "my clinical opinion, this patient is (check mark) still at risk for violent behavior."

Patient #7's medical record also contained a completed form identified as an "Application For an Involuntary Emergency Hospitalization For Mental Illness", (this is a legal process whereby an individual with symptoms of severe mental illness is court ordered into a hospital for inpatient treatment), dated 1/08/13, and the "specific type of serious harm - thought problem" was documented as, "Suicidal Ideation/Homicidal Ideation", and the physician documented, "Pt. States "I thought about hurting .... (stepfather)", punched hole in wall at home". In the section of the above form labeled, "Health Of Patient", a check mark was beside Homicidal or Suicidal Tendency" and Homicidal was circled.

Review of Hospital A's assessment and referral center intake form showed Hospital B requested a psychiatric bed from Hospital A for the patient on 1/9/13. Review of Hospital A's Assessment and Referral sheet showed the following documentation: "1/9/13, 3:30 Pt (Patient) was presented to Assessment for inpt (in patient) treatment. Pt has Asperger's, ADHD (Attention Deficit Hyperactivity Disorder) and Pervasive Dev. (Development) D/O (disorder). Pt reviewed w/ (with) Dr..... (on - call Psychiatrist) and pt was denied since symptoms did not appear to represent MI (Mental Illness), but rather developmental issues. Recommended referrals to DDSN (Department of Disability and Special Needs) and/or to a .... (Psychiatric) hospital ". The facility failed to ensure that their "Admission Criteria - Adult Behavioral Care Services" policy was followed by not accepting Patient #7 on 1/09/2013 with an identified psychiatric EMC (Emergency Medical Condition). The medical records were sent to Palmetto Health Richland as requested which indicated that Patient #7 was a danger to himself and others.

Review of Hospital A's bed census on 1/9/13 verified Hospital A had a bed census of 31 psychiatric patients with a capacity of 52 psychiatric beds. The hospital failed to ensure that their "Emergency care/EMTALA" policy and procedure was followed as evidenced by refusing to accept Patient #7 on 1/9/2013, an appropriate transfer who required psychiatric specialized capabilities or facilities that were available at Palmetto Health Richland.

On 1/11/13 at 0905, Social Worker #1 reported that the Social Worker is responsible for completing the assessment and referral log during day time hours, and the information on the log is the information received from the telephone calls from other hospitals requesting a patient's admission. Social Worker #1 reported, "If a patient requires admission after hours, then the patient goes through the emergency department. Any patients in outlying areas go to their nearest emergency room, and they (emergency room) keep them until the next morning."

On 1/11/13 at 1405, during an interview with Licensed Masters Social Worker #2, he/she revealed that "for any hospital that contacts us, we ask for the medical record and review it with the psychiatrist on call, and we will make a decision if we are going to admit the patient, and once the decision is made, we get in touch with facility".

On 1/10/13 at 1205, during an interview with the Medical Director, the Medical Director revealed that patients are refused if they are "no longer needing level of care-no longer acute" based on the clinical information presented by the sending facility.