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Based on records review and interviews, the hospital failed to follow its own Intake Policy to ensure that appropriate transfer of individuals are accepted if the hospital has the capability and capacity at the time of the request to accept the transfer of 13 of 19 patients records reviewed of 20 (1, 2, 4, 5, 6, 7, 9, 12, 13, 15, 17, 18, 20).

Findings:

Review of the hospital's license revealed the hospital was licensed for 60 beds.

Review of the " Admission Criteria: Clinical Appropriateness " policy for Greenbrier Behavioral Hospital (GBH) reflected " Admission will be offered to adult psychiatric patients, 18 years of age or older, patients who have suffered a decrease in their everyday level of functioning. The following disease processes or symptoms may warrant admission to the program, but admission is not restricted to ... ...Appropriate ... ... ...
3. Excessive use of alcohol, need for detox.
4. Excessive use of drugs, chemical substances ... ... ... ... ... ... ... ...
10. Acute disturbance of affect, behavior,or thinking................"

It was also noted in the policy that patients with chronic medical illnesses in addition to a psychiatric diagnosis may be potentially appropriate and accepted for admission.

Review of the hospital's "Intake Policy" reflected the procedure for "Intake Assessment of Phone Inquiries" included that sufficient clinical information would be gathered concerning each individual in order to determine need for hospitalization. It was also noted that the decision to hospitalize would be based on the presenting clinical criteria and consideration for the patient's safety and well-being.

Further review reflected that "The designated clinician processing the intake call will complete an Intake and Initial Inquiry Information Assessment documenting date and time of call, caller data, patient data, referral source, presenting problem, suicidal/homicidal assessment if applicable, duration/course of symptoms, medical problems, current medications, tuberculosis screening, special physical needs, current stressors, previous psychiatric treatment, initial diagnostic impression, ability to participate.......The Intake Assessment Form and all supporting documentation shall be kept in the Intake Office for no longer than 72 hours if the patient is not admitted..... I. The Psychiatrist makes the final decision on admissions based on presenting clinical criteria or the decision to refer the individual to another level of care if he/she is not appropriate for hospitalization........"

Review of the hospital's Initial Intake Assessment & Inquiry Information form revealed the form was revised in 8/2011 and there were 3 pages of the form to be completed by staff. Review of the form reflected a place for "insurance information" to be included on the form.
Review of patient records revealed the following:

Patient #1
Review of the Initial Intake Assessment & Inquiry Information form for patient #1 reflected an intake inquiry was made on 10/29/11 at 12:30 a.m. The information documented on the form included: first name of caller, age and sex of patient, staff's first name, date, and time of intake call. There was no documentation of the patient's name noted on the form. The referral source was noted to be Hospital D and the patient's presenting problem was listed as "pt. loss extremely violent behavior police were called/pt. hit family member". There was a check mark noted on the form which indicated the patient was a danger to others. Further review reflected page 2 of the form was blank, and the last page of the form had the word "loss" noted under the time section. There was no documentation of the clinician's signature noted on the last page of the form.

Review of the hospital's referral log reflected the intake call was received from Hospital D's emergency department.

Review of documentation submitted on 12/9/11 by S12, Director of Nursing (DON) revealed the hospital's census on 10/29/11 was 15 patients on Unit A with 1 blocked bed; 13 patients on Unit B and 11 patients on Unit C for a total of 39 patients in the hospital.

There was no documented evidence provided by the hospital to reflect that they were at capacity on 10/29/11.

Interview on 11/30/11 at approximately 12:05 p.m. with S9, M.D. revealed the documentation noted on the form was not justification for refusal of patient.

Patient #2
Review of the Initial Intake Assessment & Inquiry Information form for patient #2 reflected the form was completed on 11/3/11 at 12:16 (no indication of a.m. or p.m.). There was no name of the patient indicated on the form. The only information included on page 1 of the form included the first name of the staff, S17 (no title), date, time, age and sex of the patient being referred. There was no information documented on page 2 of the form, and the only information on page 3 included the date and time (no indication of a.m. or p.m.).

There was no documented evidence to indicate why the patient was not accepted. Review of the referral log indicated "at capability". Review of a staffing pattern form presented by S1, Administrator for 11/3/11 reflected there were 12 patients on Unit A, 10 patients on Unit B and 8 patients on Unit C for a total of 30 patients.

Interview with S1, Administrator on 11/29/11 at approximately 5:00 p.m. revealed the hospital was currently licensed for a total of 60 beds.

Interview on 12/9/11 at 1:40 p.m. with Hospital L's Risk Manager revealed patient #2 was a patient in their hospital's emergency department, and she confirmed that the hospital attempted to transfer the patient to GBH.

Patient #4
Review of the Initial Intake Assessment & Inquiry Information form reflected a referral was called in by and "ER, RN" on 11/7/11 at 4:27 p.m. The referral source was listed as Hospital F emergency room. There was no information concerning the patient's name and presenting problem. Documentation on page 2 of the form reflected "@ capability".

Review of the Staffing Pattern form completed by the hospital on 11/29/11 reflected that on 11/7/11 there were 12 patients on Unit A; 13 patients on Unit B and 15 patients on Unit C for a total of 40 patients.

Patient #5
Review of the Initial Intake Assessment & Inquiry Information form reflected a referral was called in on 11/4/11 from Hospital G for a 30 y/o female. Documentation on the form reflected "loss due to violent behavior per [S9, M.D.]. Review of the last page of the form reflected "pt declined by [S9]". The clinician's signature was noted to be S5, Intake Coordinator

Interview on 11/30/11 at approximately 12:05 p.m. with S9, M.D. revealed the information provided on the form was "definitely not justified denial by documentation". S9, M.D. stated he knew what admission criteria indicated, however the hospital was not a "detox" facility. S9, M.D. further indicated that the hospital would do "detox" under certain conditions.

Interview with S5, Intake Coordinator, on 11/30/11 at 10:40 a.m. revealed she vaguely remembered the patient. However, S5 stated she spoke with S9, M.D. and he was concerned they wouldn't be able to care for the patient due to the patient's violence in the emergency department which required medications that were not effective. S5, stated she was recalling the above information from memory and confirmed there was no documented evidence of that information.

Interview on 12/12/2011 at approximately 11:00 a.m. with S23, RN, Quality Manager at Hospital G revealed patient #5 was a patient in their emergency department. Further interview with S23 and review of documentation faxed to the surveyor, reflected patient #5 was not accepted as an admit at GBH due to the hospital having "no beds".

Review of documentation received from GBH's Administrator (S1) on 12/12/11 revealed there were a total of 33 patients in the hospital on 11/4/11. Further review reflected there were 12 patients on Unit A, 10 patients on Unit B and 11 patients on Unit C.

Patient #6
Review of the Initial Intake Assessment & Inquiry Information form for patient #6 reflected a referral was made from Hospital G on 11/10/11 at 3:55 a.m. Documentation reflected "loss due to violent behavior by S9, M.D." . There was no documentation of the patient's presenting problem or the name of the patient noted on the form. The staff completing information on the form was noted to be S8, RN.

Interview on 11/30/11 at 11:20 a.m. with S8, RN, revealed she could not remember the patient's information. However, S8 stated she remembered getting the packet for the patient who was extremely violent. S8, RN, stated she called S9, M.D. and S9 stated that due to the patient's violent behavior and other patients on the unit, it was best not to take the patient. S8, RN confirmed the form was not completely filled out and stated that the only time the intake form is filled out completely is when the patient has been accepted.

Interview S9, M.D. on 11/30/11 at approximately 12:05 p.m. revealed violent behavior was no reason to deny admission. S9 revealed he did not remember receiving a call about patient #6, and S9 stated the nurse should never refuse a patient without going to the physician.

Interview on 12/12/2011 at approximately 11:00 a.m. with S23, RN, Quality Manager at Hospital G revealed patient #6 was a patient in their emergency department. Further interview with S23 and review of documentation faxed to the surveyor, reflected patient #6 was not accepted as a patient at GBH due to the hospital having "no beds".

Review of the hospital's staffing pattern reflected there were 12 patients on Unit A; 12 patients on Unit B; and 14 patients on Unit C for a total of 38 patients in the hospital on 11/10/11.

Patient #7
Review of the Initial Intake Assessment & Inquiry Information form dated 11/15/11 beginning at 6:02 p.m. and completed by S5, Intake Coordinator at 7:50 p.m. revealed a referral was received from Hospital A. Review of the documentation reflected the patient was committed by PEC (Physician ' s Emergency Certificate) and the patient ' s presenting problem reflected " ETOH - 2-3 drinks/day. Pt was arrested on 11/8/11 for threatening life of spouse & child & since his arrest he has also made threats to have his spouse arrested " . It was documented that patient #7 was a danger to others " HI (per wife) & hostile, pt. denies SI per OPC " .

Further review of documentation at the bottom of the form reflected the patient was not admitted to the hospital and it was noted " loss- declined by [S9] and [S14] due to = " " too many factors to this one. Detox potential, possibility for violence, was recently arrested, would be difficult to tx " . Further review of the additional pages of the Intake Assessment form reflected an initial diagnostic impression of " Bipolar and Post Traumatic Stress Disorder (PTSD). It was noted that the patient was not admitted and was referred to a " detox " facility. Documentation reflected the patient was not admitted due to " loss-pt going through withdraws (elevated BP & heart rate) " . It was noted that insurance information was noted on the form.

Review of the hospital's referral log reflected the referral for patient #7 was generated from Hospital A's emergency department.

Interview with S9, Medical Director, on 11/30/11 at approximately 12:05 p.m., concerning patient #7 revealed he (S9) stated he didn't ' t get a straight answer from the emergency department at Hospital B. S9, M.D. stated there was nothing in the paperwork indicating the patient ' s primary diagnosis was psychiatric. S9 stated when the primary diagnosis is alcohol then the patient is not appropriate for admission to the hospital. S9, M.D. further stated it was a " second tier denial ".

Patient #9
Review of the Initial Intake Assessment & Inquiry Information form dated 11/15/11 reflected an intake was received at 2:14 a.m. by S18 (no title indicated). The name of the patient was not noted on the form, and there was no caller data noted. Documentation reflected it was a 54 y/o male and the referral source was Hospital N. Further review reflected the only information noted under "Presenting Problem" was "Due to Extremely violent behavior." There was no other identifying information noted nor was there a clinician's signature noted at the end of the form.

In a continued interview with S9, M.D. at approximately 12:05 p.m. revealed "it doesn't say referred to me".

Review of the hospital's referral log revealed the notation "loss-declined by Medical Director S9.

Review of the hospital's staffing pattern reflected there were 13 patients on Unit A; 15 patients on Unit B; and 12 patients on Unit C for a total of 40 patients.

In a telephone interview on 12/12/11 at 1:40pm, Unit Director of Emergency Department (ED) S25 provided the name of Patient #9 and confirmed Patient #9 came to the ED on 11/15/11 at 1:00pm with the diagnosis of schizophrenia. She further indicated Patient #9 was violent and brought to the ED by the sheriff's department. S25 indicated the case manager documented that she was told by the staff at Greenbrier that due to Patient #9's violent behavior and the acuity of the patient, they would not be able to accept the referral.

Patient #12
Review of the Initial Intake Assessment & Inquiry Information form dated 11/16 at 9:06 p.m. revealed a referral was made from Hospital A for a 63 y.o female. Review of the "Presenting Problem" revealed increased "depression, was told today that she would need 8 more weeks of bedrest due to [right] knee SI - told 3 diff. people that she would kill herself [with] a box cutter". Further review reflected the patient was "declined by [S19, RN, NP] due to renal failure: elevated BUN & creat". Continued review on page 3 of the form revealed patient #12 was not admitted due to "possible renal failure elevated BUN & creatinine.

Review of patient#12's emergency room documentation which was included with the referral packet revealed the patient's clinical impression was depression and suicide ideation. The patient's Blood, Urea and Nitrogen (BUN) level was noted to be 25 and the creatinine level was 1.9. Documentation in the ER record reflect that the patient's chief complaint was "Psych Related". Review of the Physician's Emergency Certificate (PEC) dated 11/16/11 reflected the patient's physical findings consisted of right knee post surgical changes and urinary tract infection.

There was no documented evidence to reflect that S19, RN, FNP discussed the patient's condition with S20, M.D.

Interview with S9, M.D. on 11/30/11 beginning at approximately 12:05 p.m. revealed there was no documented evidence that the above case was discussed with him. S9, stated that both the psychiatrist and the medical doctor (S20) would be called in a case such as the above.

Interview with S5, Intake Coordinator on 11/30/11 beginning at approximately 2:50 p.m. revealed she reviewed the above case with S19, RN, FNP because the laboratory values were abnormal and the patient's Blood Urea Nitrogen (BUN) and creatinine levels were elevated. S5, stated the patient was in renal failure and could not be handled at their hospital. S5, Intake Coordinator further stated that she did not speak with the psychiatrist about the patient. S5 revealed that if "medical" said no then they would not "run by psychiatrist" if the patient was not medically appropriate.

Review of the hospital's staffing pattern form reflected there were 16 patients on Unit A; 13 patients on Unit B and 9 patients on Unit C for a total of 38 patients on 11/16/11.

Patient #13
Review of the Initial Intake Assessment & Inquiry Information form dated 11/19 at 11:55 p.m. revealed a referral for placement was sought for a 43 y/o male from Hospital H. There was no name of the patient noted on the referral form. The documented clinical reason for not admitting the patient revealed "detox potential". The clinician signature noted on the form was S8, RN.

Review of the hospital's referral log revealed the notation "loss-drug-seeking behavior".

Interview with S8, RN on 11/30/11 at 11:20 a.m. confirmed she was the nurse who obtained the referral information on patient #13. S8, RN stated she remembered the patient was "chronic alcohol abuse" and the hospital was not a "detox per se facility" she felt the patient's best interest was to be placed in a facility where his needs could be addressed. S8, RN stated the night shift nurse could determine refusal based on the patient packet. S8, stated she did not know how the referral log was generated. S8, RN confirmed she did not remember the referral totally because the information was limited.

Review of the hospital's staffing pattern form revealed there were a total of 19 patients on Unit A; 12 patients on Unit B; and 11 patients on Unit C for a total of 42 patients.

In a telephone interview on 12/12/11 at 11:50am, Director of ED S26 provided the name of Patient #13. She further indicated the ED nursing documentation revealed Patient #13 presented with complaints of a headache and back pain and told the nurse he would not speak with anyone until he was given pain medication. S26 further indicated Patient #13 refused Toradol and requested intravenous pain medication and asked the nurse why the physician would not give him Morphine. S26 indicated the social worker's documentation revealed that Patient #13 reported that he had called an ambulance due to back pain. He further indicated (per the social worker's notes) he was depressed and had been for about a year since his wife hung herself and his daughter was killed in a car accident. He denied alcohol and drugs and said he reported having a difficult time around the anniversary dates of the events mentioned above. S26 indicated the social worker placed a call to Greenbrier at 0021 (12:21am) along with calls to several other hospitals, but there was no documentation of the conversation between the social worker and the staff at Greenbrier. S26 indicated it was not documented by the social worker that Greenbrier refused the admit.

Patient #15
Review of patient #15's " Initial Intake Assessment &Inquiry Information form " revealed the only information on the form pertaining to the patient was the age, sex, referral source and clinical reason for not admitting the patient. Review of the form reflected a referral was made on 11/26 at 10:03 p.m. from Hospital C to GBH concerning a 59 y/o male. There was no information noted on the form to indicate the patient ' s presenting problem. Documentation reflected patient #15 was not medically appropriate because the patient had a decreased hemoglobin and hematocrit, decreased white blood count and decreased blood pressure. Further review of the form reflected the staff noted on the form was S15, LPN and S16, RN. There was no last name of the staff indicated on the form.

Interview with S9, M.D. concerning patient #15 revealed there was no evidence that the information was given to the M.D. for referral. S9, M.D. revealed the decreased hemoglobin and hematocrit, decreased white blood count and decreased blood pressure would not be justified for denial. When the surveyor asked S9, M.D. if the emergency department patient had to be medically cleared before seeking transfer, S9, M.D. stated " that's what's supposed to happen ".

Information received from Hospital C, concerning patient #15, revealed GBH called and stated there were "no beds tonight, will save information for morning."

Review of information received from the hospital on 12/9/11 reflected the hospital's total census was 21. There were 9 patients on Unit A and 12 patients on Unit C. Further review reflected Unit B was closed and there were 3 "blocked" beds on Unit C.

Patient #17
Review of the Initial Intake Assessment & Inquiry Information form for patient #17 revealed a referral dated 11/7/11 at 5:30 (no a.m. or p.m. indicated) from Hospital L for placement of a 34 y/o male. Documentation on the form reflected " Loss med. Issues per [S21, M.D.] ETOH Abuse " . It was further noted that the patient had a history of seizure disorder, low dilantin level and chronic alcohol history.

Interview on 11/30/11 at approximately 12:05 p.m. with S9, M.D. confirmed there was no evidence that psychiatry was involved in the decision to refuse the patient.

Review of the hospital's staffing pattern form reflected there were 12 patients on Unit A, 13 patients on Unit B and 15 patients on Unit C for a total of 40 patients. Review of the hospital's referral log reflected patient #17 was referred form Hospital L's emergency room.

Patient #18
Review of the Initial Intake Assessment & Inquiry Information for patient #18 revealed a referral dated 11/16/11 at 7:15 p.m. from Hospital J' emergency department for placement of a 25 y/o female. There was no documented evidence of the patient ' s name noted on the form. Review of the patient ' s " Presenting Problem " revealed " Loss due to detox ETOH level (97). There was no documentation to reflect the physician was made aware of the referral. Review of the hospital ' s referral log revealed the hospital was at capacity.

Review of the hospital ' s staffing pattern for 11/16/11 revealed there were 16 patients on Unit A, 13 patients on Unit B and 9 patients on Unit C for a total of 38 patients.

Patient #20
Review of the Initial Intake Assessment & Inquiry Information form dated 11/9/11 at 11:22 p.m. by S8, RN revealed a referral was made from Hospital K for placement of a 27 y/o male. Review of the form revealed the patient was not admitted due to " at capability " .

Review of the hospital's referral log reflected patient #20 was referred by Hospital K's emergency department.

Review of the hospital ' s staffing pattern form revealed that on 11/9/11 there were 13 patients on Unit A, 15 patients on Unit B and 16 patients on Unit C for a total of 44 patients.

Interview on 11/30/11 at 11:20 a.m. with S8, RN, revealed she did not remember the patient by age, but the hospital probably did not have a male bed. S8, RN revealed capability and capacity were used interchangeably. S8 further stated staff based their judgement to admit on a form called " red flag " . S8, RN stated that sometimes they deviate from " red flag " , and she revealed that she had never been given the hospital' s admission criteria. S8, RN stated that she had minimal education by hospital intake prior to taking intake calls. S8, further stated that she had never had education related to EMTALA laws or regulations.

Review of the personnel file for S8, RN revealed there was an incomplete competency form in her record and there was no documented evidence to reflect she had been properly trained concerning EMTALA and Intake procedures.

Interview with S3, Corporate Compliance Officer on 11/30/11 at approximately 4:00 p.m. revealed an unauthorized " Intake Admission Protocol " was put in place in August by S22, Director of Intake. S3, Corporate Compliance Officer stated that an internal investigation was conducted as to the origin of the " red flag protocol " and staff was directed to disregard the protocol as soon as it was brought to the attention of the Compliance officer. S3, Corporate Compliance Officer stated all staff were made aware that the " red flag protocol " was not to be utilized in the hospital.