HospitalInspections.org

Based on medical record review, review of Referral Intake Log, review of Referral Intake Assessment, review of Bed Availability Calendar, and staff interviews, it was determined the Hospital failed to ensure compliance with CFR 489.24.
Findings include:

1. The Hospital failed to ensure acceptance of transfer for a Psychiatric/Behavioral Health patient for which the hospital has specialized services for treatment and the capacity to provide care. See deficiency cited at A-2411.

Based on medical record review, review of referral intake logs, intake assessment, bed availability calendar and staff interviews, it was determined the Hospital failed to accept the transfer of 1 of 1 (Pt #1) individuals with psychiatric behavioral health diagnoses to the hospital's specialized behavior health unit when both capability and capacity to treat the individual existed.
Findings include:

1. The medical record of Pt #1 from the transferring hospital was reviewed on 4/16/13. The medical record indicated Pt #1 presented to the Emergency Department (ED) at the transferring hospital on 4/6/13 at 7:37 PM escorted by the Police Department (PD). A Medical Screening Examination and Psychiatric Evaluation were completed with the clinical impression indicated as "Depression, Suicide Ideation." Documentation indicated Pt #1 was treated and stable for transfer. Documentation in the crisis contact narrative indicated "Called Covenant 11:45-declines to previous history-3/3-3/12, 2/22-2/27, 12/12-12/19, 10/19...."
The medical record of Pt #1 from the receiving hospital was reviewed on 4/16/13.
Documentation indicated Pt #1 was involuntarily admitted to the receiving hospital on 4/7/13 at 7:45 AM. Documentation indicated Diagnoses: Axis I: 1. Bipolar disorder, not other specified. 2. Post-traumatic stress disorder, chronic. Axis II: Borderline personality disorders..."

2. A review of the Behavioral Health Referral Intake Log (2/1/13-5/15/13) from Presence Covenant Medical Center was completed during the survey. The Intake Log included Pt #1 with a referral on 4/6/13 at 2330 from the transferring hospital with the disposition as "UTA #4 violence", unable to admit/ does not meet criteria based on Scope of Care policy.

3. A review of the intake assessment of Pt #1 indicated Pt #1 was not admitted for transfer with the "Reason for Denial: Does not meet admission criteria, or is otherwise excluded from admission based on Scope of Care policy" marked with a check. In addition the word "danger" was written below this area of the form.

4. A calendar completed by the Manager of the Behavioral Health Unit (BHU) (E#1) was presented to indicate the bed availability on the BHU from 4/1/13 through 4/7/13. The calendar indicated there were 9 beds available on 4/6/13 at the time the referral of Pt #1 was made.

5. During an interview with the Manager of the BHU (E#1) on 4/15/13 at 1355 PM, E#1
reported the process for referral and admission begins with receiving and evaluating
information from the transferring hospital. This information is then reported to the Psychiatrist
on call and the final decision is made by the physician. E#1 reported she has knowledge of Pt
#1, indicating she "knows Pt #1 well, she is violent, causing harm to self and staff in the past.
Pt #1 is vengeful and purposeful in her actions, often aggressive and at times has required
restraint for safety." When asked if beds were available at the time of Pt #1's referral, E#1
reported some beds were "blocked" due to patients not being appropriate for a roommate,
but there were beds available. E#1 provided written information describing patients in the
BHU on the day of the referral which included, 2 patients described as "extremely psychotic,
agitated, aggressive, verbally aggressive", 1 patient "agitated at co-pts, confused" who started
an altercation with another patient, and 1 patient with "bizarre behaviors, hyperactive and labile,
requiring a great deal of staff time."

6. During an interview with the Medical Director BHU/Psychiatrist (E#2) on 4/16/13 at 0900
AM, E#2 was asked if he had knowledge of Pt #1 and replied he has known her since last
August when she began to come to the hospital for care. E#2 reported he recalled the referral
and discussion with the nurse regarding Pt #1's situation and needs. E#2 reported Pt #1's
personality disorder is more difficult to treat and felt she was in need of a long term care facility
where there is a strict schedule and more time to gain control over unpredictable behaviors. E#
2 reported it was his decision not to admit Pt #1 because of the knowledge of Pt #1's behaviors
and physical harm to staff during previous hospitalizations.