HospitalInspections.org

Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to provide recipient hospital responsibilities (see A-2411) resulting in the potential for less than optimal outcomes for all psychiatric patients transferred to the facility.

Based on interview and record review, the facility failed to follow through with the acceptance of 1 (#21) of 1 psychiatric patients who had been transferred and was on-site at this receiving hospital, resulting in delay of treatment and potential for less than optimal outcomes. Findings include:

On 4/12/24 at 1645, interview with Physician S at Facility A revealed that Facility B accepted patient #21 then would not let the patient on the psychiatric unit when the patient got there. The staff would not get the receiving psychiatric physician on the phone for further discussion and would not let the patient in the Emergency Department at Facility B. The facility staff sent the patient back to Facility A by ambulance in inclement weather.

Medical record review from the transferring Facility A revealed that the patient of concern was a 75-year-old female who was initially brought to Facility A Psychiatric Emergency Department (ED) on 8/23/23 at 1924. The patient's daughter signed the petition on 8/23/23 due to the patient was increasingly paranoid and acting in a bizarre manner. There was a court "Order for Examination/Transport" signed on 8/23/23 by the judge. Patient #21 required inpatient psychiatric hospitalization but there were no current beds available at Facility A. Arrangements were made to transfer the patient to another Facility B with psychiatric beds available on 8/24/34 at 1103. The patient was transferred by ambulance to the receiving hospital on 8/24/23 at 1600. On 8/24/23 at 1941 the patient was returned by ambulance due to receiving Facility B "refused to accept her due to a staple in the petition (legal paperwork)."

On 4/16/24 at approximately 1030, interview with ED Supervisor G from facility B revealed that he did not recall the case. He stated that psychiatric patients either come through the ED or go directly to the psychiatric units. On 4/16/24 at 1130, interview with the Nurse Manager of the Psychiatric Units (adult and geriatric) revealed that she recalled one case where the transferring physician was very upset that they would not take the patient due to staples or holes in the paperwork.

On 4/16/24 at 1615, interview with Psychiatric Nurse N from Facility B revealed that she recalled an issue with the petition paperwork for a patient. She stated that the original copy was stapled and they do not accept stapled paperwork. She stated that another nurse talked to the transferring physician as well. Phone interview with Psychiatric Medical Director R revealed that he was made aware of the incident and verified that Facility B did not accept stapled petition paperwork.

On 4/17/24 at 1050, phone interview with Psychiatric Nurse O revealed that she had also spoken with the transferring physician. She stated that the facility did not accept petition paperwork that had been stapled. She stated that the ambulance drivers also tried to take the patient to Facility B Emergency Department. Nurse O stated that the Nurse Manager and Medical Director were notified of the situation. On 4/17/24 at approximately 1100, interview with Accreditation Manager A revealed that she could not find the requirement for rejection of a patient due to stapled petition paperwork, nor was there a facility policy/procedure regarding non-acceptance of a psychiatric patient due to stapled petition paperwork.