HospitalInspections.org

Based on review of policies, medical records, documents, and interviews with staff, the Critical Access Hospital (CAH), a Medicare participating hospital with specialized psychiatric capabilities and capacity failed to enforce its Emergency Medical Treatment and Labor Act (EMTALA) policies and accept an appropriate transfer of one out of 36 patients with a unstable psychiatric emergency medical condition. (Patient #17)

Failure to ensure staff followed their policies and accept an appropriate transfers of a patient with an unstable psychiatric emergency medical condition resulted in nearly a 72 hour delay for Patient # 17's psychiatric evaluation and treatment, and placed the patient at risk for harm and/or death.

Findings include:

A hospital policy titled, "Admission and Exclusion to Psychiatric Program" Revised: 4/7/2015 included in part, "...PURPOSE: To assist professionals at St. Anthony...to provide quality inpatient treatment for patients 19 years of age or older...INCLUSION CRITERIA...patient demonstrates...as the result of a mental disorder, he or she presents a danger to himself/herself or others...patient's orientation, perception, memory, intellect, or judgments are severely impair due to a mental disorder, behavioral or cognitively impaired will be considered appropriate ...The provider on-call with the Nurse Manager or designee may reserve the right to determine that we are no longer able to accept patients due to acuity or the mix of patients..."

2. A hospital document titled, "BMU (Behavioral Medicine Unit) Referral" Date: 6/25/16, Time: 5:35 AM, ER (Emergency Room) stated in part, "...[Patient #17]...suicidal ideation...plan: cut wrists...Voluntary (No court order.)...Fax Received...Advanced Practice Registered Nurse - Psychiatric Mental Health [APRN-PMH A] ... Patient accepted only if a 48 hour hold or a committal based on her history of leaving and coming back the same day and refused placement... [ED RN K] at transferring hospital stated a 48 hour hold or a court committal is not appropriate. The patient is willing to be transferred and admitted. [APRN A] stated will only accept the patient transfer if the patient had a 48 hour hold or a court committal..."

A hospital document titled, "St. Anthony Regional Hospital Variance Report" Dated 6/27/16, completed by the Inpatient Psychiatric Manager included in part, "...Date of incident 6/25/16...Additional information...Had a referral from [transferring hospital], for a patient in the emergency room. There were several calls back and forth to get all the information & labs. The patient left the emergency room against medical advice & then returned later, saying she was suicidal again. RN reported to me on Monday 6/27/16 that APRN A told them that we wouldn't consider admission unless they got a court committal. I informed RN that this is a violation of EMTALA, we cannot require a court committal ...What immediate action was taken:...Manager was not aware until Monday morning...How could this have been prevented:...Education of staff on EMTALA laws and violations...What further corrective action is required to prevent reoccurrence:...Will discuss with Nurse Practitioner and educate staff..."

A hospital document titled, "Medical Staff Bylaws" Dated 2016, included in part, "...The prerogatives which may be extended to an AHP (Allied Health Professional) shall be defined in the Medical Staff Rules and Regulations or Hospital policies. Such prerogatives may include: b) For Psychiatric Mental Health Advanced Practice Registered Nurse, psychiatric patients may be admitted, discharged, and managed by the psychiatric nurse practitioner, but the sponsoring physician will be the psychiatrist of record for the admission.. All transfers into the hospital are made through Quality Management. They will receive initial contacts, documentation and assess for appropriateness for our hospital. After consultation with the patient's attending physician arrangements for transfer will be made. Physician to physician report is completed prior to the transfer of the patient to this facility..."


3. Review of Patient #17's ED (Emergency Department) medical record faxed from the transferring hospital to St. Anthony's on 6/24/16 at 6:48 PM revealed the following documentation:

a. On 6/24/16 at 1:51 PM, ED RN L, documented Patient #17 arrived in ED.

On 6/24/16 at 2:28 PM, ED RN L, documented Patient #17 was thinking about hurting/harming self and attempted suicide in the past.

b. On 6/24/16 at 4:12 PM, ED RN T documented the following:

Presenting Problem: Suicidal Ideation. Patient reports she still feels suicidal and would like to be readmitted. Patient reports she would cut her wrists if she is discharged from the ED.

History of Psychiatric Treatment: Patient was discharged earlier this morning from inpatient at the patient's insistence to go to court. Patient presented back to the ED and stated she is still suicidal and would cut her wrists.

Suicidal Ideation: Patient reports she would cut her wrists today if she is not re-admitted to mental health.

Previous Self Harm Plans: Patient reported prior overdose attempt.
Previous Suicidal Plans: Cut wrists and overdose.

c. On 6/24/16 at 5:19 PM, ED RN T documented the following:

Additional Assessment:
Doctor Consulted: Psychiatrist U consulted and recommended inpatient mental health admit.
Recommendation: Inpatient hospitalization
Patient/Family Response: Patient informed that no beds are available at transferring hospital, will attempt to locate a bed for her somewhere in the state.


4. Review of Patient #17's ED medical record the surveyor received from the transferring hospital on 6/29/16 revealed the following documentation:

a. On 6/24/16 at 8:16 PM, ED RN V documented the following:

Suicide Risk:
Have you attempted suicide in the past: Yes
Are you currently thinking about hurting/harming self: Yes
SAD (Suicide Assessment) Score: 5 (A score of 3 to 6 consider for hospitalization or very close follow-up.)

b. On 6/25/16 at 9:00 AM, Behavioral Health RN W documented the following:

Behavioral Health Assessment:

Safety - Precautions Type: Suicide
Psych Precautions: Suicide Risk
Risk Factors - Suicidal Ideation: Patient reports she is still having suicidal thoughts.
Affect: Flat

c. ED Physician N documentation included the following:

On 6/24/16 at 8:38 PM, the patient stated she continued to feel suicidal. Bed placement is still pending at this time.

On 6/24/16 at 9:38 PM, St. Anthony's is requesting that the patient be court committed. The patient is agreeable to go to St. Anthony's. At this time there is no legal reason to court commit somebody who is cooperative and could put us in a position where we get in trouble for court committing a cooperative patient. St. Anthony's stated that they will refuse the patient based upon the lack of a court order.


5. During a telephone interview on 6/27/16 at 5:00 PM, ED Physician N from the transferring hospital, reported Patient #17 presented to the ED on 6/24/16 with a complaint of suicidal ideation, a plan to slit her wrists, depression, a history of bipolar, and borderline personality disorder. ED Physician N reported on-call Psychiatrist U determined Patient #17 required an admission for mental health treatment. ED Physician N reported, there were no psychiatric beds available at the transferring hospital. ED Physician N reported, the patient was cooperative and willing to be admitted at St Anthony's Regional Hospital. ED Physician N stated, if a patient is cooperative and willing to be admitted a court order or 48 hour hold is not needed. ED Physician N indicated that Patient # 17 remained in the transferring hospital's ED for nearly 72 hours before an inpatient psychiatric bed was finally located.

During an interview on 6/28/16 at 1:50 PM, the St. Anthony's Behavioral Medicine Unit (BMU) Nurse Manager reported, providers from transferring hospitals call the BMU directly for bed placement. All patients must be medically cleared before coming to the BMU. A BMU nurse will take the call and complete a BMU referral sheet, and use the Admit Criteria Policy to help with acceptance or rejection of the referral.

During an interview on 6/29/16 at approximately 10:30 AM, the St. Anthony's ED Director reported, the ED providers do not get involved with accepting transfers of mental health patients from other hospitals. When a hospital calls to request a psychiatric bed placement the call is transferred to the BMU. The ED Director stated, when we have mental health patients in our ED we follow the same procedure.

During an interview on 6/29/16 at 12:00 PM, the St. Anthony Inpatient Psychiatric Manager stated, "I told APRN A, a 48 hour hold or court committal is not required for admitting a patient to the BMU. The Inpatient Psychiatric Manager reported, the BMU RN receives the initial telephone call and begins the referral documentation. The BMU RN would ask the transferring hospital about the patient's medical diagnosis and if the patient is a court commitment, a 48 hour hold, a county hold, or a voluntary admission. The Inpatient Psych Manager stated, the BMU RN would ask the transferring hospital to fax a medication list, metabolic profile, alcohol level, TSH (thyroid studies), acetaminophen (Tylenol), and salicylate (aspirin) levels. The BMU RN and the provider discuss the patient, related to the information provided regarding the diagnosis, and waits for the information to be faxed. The Inpatient Psychiatric Manager stated, "After an undetermined amount of time, the BMU RN contacts the transferring hospital and at that time the RN may find out a bed was found at different facility."

During an interview on 6/30/16 at 9:45 AM, Advance Practice Registered Nurse (APRN) A stated, I remember the patient [Patient #17], she needed to be on a 48 hour hold for acceptance to be admitted to the BMU. APRN A stated, Patient #17 was at risk for changing her mind about staying in the BMU and may leave. APRN A stated, suicidal ideation is enough reason to get a 48 hour hold. APRN A stated, "My decision to accept or decline the patient was based on the 48 hour hold. This has never been a problem in the past. It is common to have a 48 hour hold or a committal and it wasn't an issue to get one in Kentucky." APRN A stated, "No 48 hour hold was placed on this patient because she was willing to come and I disagreed." APRN A reported, [Patient #17] could not be trusted to stay in the BMU after she left and came back to the transferring hospital ' s ED. Leaving the transferring hospital ' s ED and coming back later showed the patient was unstable. APRN A reported she trained with the BMU Medical Director for approximately 1 week doing rounding and reviewing old referral sheets to understand the procedure for accepting and declining patients for admission to the BMU. APRN A reported she did not receive EMTALA training.

During a telephone interview on 6/30/16 at 11:10 AM, BMU RN F stated, I took the initial call from the transferring hospital for Patient #17 on 6/24/16. I requested some background information, lab work, and I was told a 48 hour hold would be obtained for the patient so I informed APRN A. BMU RN F stated, I returned to work in the evening on 6/25/16 and continued to work on placement for the patient. BMU RN F stated, I called the transferring hospital on 6/25/16 and told a different RN that I received all the materials except the 48 hour hold and the transferring hospital reported the patient was willing to be admitted. BMU RN F stated, I contacted APRN A and she did not understand why there was no 48 hour hold because the patient was suicidal and that is enough for a 48 hour hold order from a judge.

During an interview on 6/30/16 at 9:00 AM, the St. Anthony's Inpatient Psychiatric Manager reported on 6/25/16 at 5:35 AM, the BMU had 4 patient beds available and 2 of the 4 patient beds were in 1 empty room. During a second interview on 7/1/16 at 11:25 AM, the Inpatient Psychiatric Manager reported on 6/25/16 at 7:00 PM, the BMU had 8 patient beds available beds and 2 of the 4 patient beds were in 1 empty room. The Inpatient Psychiatric Manager stated, "We had enough nursing staff, and the BMU acuity was such we could have accepted Patient #17 for admission. We had the capacity and the capability to accept Patient #17".

A hospital document titled, "BMU - ASSIGNMENTS JUNE 2016" showed on 6/25/16 through 6/27/16, APRN A, was the on-call provider for the BMU at St. Anthony's Regional Hospital.


During an interview on 7/5/16 at 11:45 AM, the BMU Medical Director stated, APRN A received 1-2 days of orientation at St. Anthony's Regional Hospital before she started seeing patients at the BMU. The BMU Medical Director stated, APRN A or any provider can call me at any time, some APRNs call more than others. They do not have to call prior to admitting a patient in the BMU. The BMU Medical Director stated, APRN A did not call me prior to when she declined Patient #17's transfer. The BMU Medical Director stated, "We do not require a 48 hour hold for any patient prior to admitting the patient in the BMU. Patient #17 did have a history of leaving and coming back, I would have asked if we needed a 48 hour hold, if not, I would not have required one. If a 48 hour hold is needed after the patient arrives it can be obtained."

During an interview on 7/5/16 at 1:45 PM, the Director of Quality Management acknowledged the hospital lacked documentation of Quality involvement in regards to tracking the BMU acceptance of patient transfers for possible violations of the Emergency Medical Treatment and Labor Act (EMTALA) violations.