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Based on record review, policy review, and staff interview, it was determined that the governing body failed to establish a policy/procedure for the transfer of patients, who require inpatient admission related to a psychiatric emergency medical condition, but are ineligible based on insurance (Patients # 1 and 5).

The findings include:

"Emergency medical condition means - "(1) A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in...(i) Placing the health of the individual...in serious jeopardy;

CMS (2007). Provision of Emergency Services - Important Requirements for Hospitals. Retrieved from: www.https://www.cms.gov/Medicare/Provider-Enrollment-and Certification/SurveyCertificationGenInfo/downloads/SCLetter07-19.pdf

A. Patient #1 was a walk-in patient to the Clinical Assessment Center (CAC) with a complaint of Suicidal Ideation (SI) with a plan.

Review of the medical record conducted on March 9, 2017 at approximately 10:30 AM revealed an "Intake Assessment" dated February 28, 2017, at 2:15 PM indicated that Patient #1 used crack cocaine as recently as four (4) days prior to coming into the CAC. The assessment also revealed that s/he had suicidal ideations with a plan to "walk in traffic." The clinical summary completed by Intake staff revealed that Patient #1 "...would benefit from treatment."

A form entitled "Level of Care Recommendation" indicated that Patient #1 met the criteria for psychiatric hospitalization. The form was signed on February 28, 2017 by Employee #8.

Review of the messaging system used to communicate internally with staff, revealed a communication from the Intake Staff to the on call physician regarding Patient #1. In the communication, Intake Staff explained that Patient #1 was a 56 year old African American male who came seeking treatment for suicidal ideation. Also noted was that the patient needed approval for admission from his/her managed care insurance company, because the facility was considered out of network.

An "Inquiry Call Display" dated February 28, 2017, at 2:15 PM revealed that Employee #8 contacted the managed care company and they were arranging transportation to an outside participating facility.

The medical record lacked documented evidence handoff communication and status of Patient #1 at the time of transfer.

A face to face interview was conducted with Employee #4, on March 9, 2017 at approximately 11:35 AM regarding the admission of patients through the CAC. S/he was queried about the facility policy and procedure for transferring patients who are assessed to require inpatient psychiatric admission for what is considered an emergency medical condition, but are not eligible for admission, for financial reasons. S/he stated that there were no policies or procedures for that instance. When asked about the communication with the receiving hospital when transferring patients because of insurance reasons, s/he stated that the facility does not have a policy or standard for that communication. S/he acknowledged the findings.

A face to face interview was conducted with Employee #1, on March 9, 2017 at approximately 4:03 PM regarding the procedure for transferring patients who are assessed to require inpatient psychiatric admission for what is considered an emergency medical condition, but are not eligible for admission, for financial reasons.; s/he responded, "we do not have a policy."

B. Patient #5 presented to the CAC as a minor with a complaint of Audio Hallucinations (AH), and Suicidal Ideation with a plan.

A review of the medical record conducted on March 9, 2017 at approximately 3:30 PM revealed, "Inquiry Call Display" completed on January 30, 2017 at 6:35 PM indicating that the patient walked in with his/her parent seeking assessment. The patient was a member of a managed care insurance company that did not participate with the facility.

A review of the medical record conducted on March 9, 2017 at approximately 3:30 PM revealed an "Intake Assessment" completed on January 30, 2017 at 6:50 PM which detailed that Patient #5 was seeking admission due to audio hallucinations to kill him/herself, with urges to cut him/herself.

A review of the "Level of Care Recommendation" completed on January 30, 2017 at 6:35 PM revealed that Patient #1 was recommended for inpatient acute care. According to the 'Inquiry Call Display', the parent contacted the manage care insurance company who requested that Patient #5 be seen in their facility.

The medical record lacked documented evidence of the status of Patient #5 prior to his/her leaving the facility. The record also lacked evidence of physician communication regarding Patient #5.

A face to face interview with Employee #4 was conducted on March 13, 2017 at approximately 10:00 AM. When asked what stabilizing treatments if any are prescribed to patients in the CAC, s/he stated that no treatments are given in the CAC unless the patient is admitted as an inpatient to the facility, and is under the care of a physician. When asked about the communication with the receiving hospital when transferring patients because of insurance reasons, s/he stated that the facility does not have a policy or standard for that communication or transferring patients under those circumstances. S/he acknowledged the findings.

Based on record review and staff interview it was determined that nursing staff failed to adequately assess and ensure a care plan was kept current, and addressed the needs of the patient. (Patient #2).

The findings include:

Patient #2 was an involuntary admission for Disorganized Thought and a past medical history of Schizoaffective Disorder.

A review of the medical record conducted on March 9, 2017 at 3:45 PM revealed a physician's order for Trazodone 100 milligrams (mg) at night for three (3) days for sleep. Review of the medication reconciliation revealed that Trazodone was a new medication for the patient.

Further review of the medical record revealed a nursing note dated January 14, 2017 at 6:00 AM. The nurse documented "...while [s/he] was getting into bed [s/he] slid on the floor at bedside. No injury or pain upon assessment ..." The physician and nursing supervisor were notified.

A review of a physician order dated January 14, 2017 at 8:45 PM directed Patient #2 to be transferred to the emergency room following a second fall at 8:30 PM. Additionally, the patient was placed on fall precautions. Documentation showed that Patient #2 was running and fell sustaining a laceration to the right side of the chin.

A review of a nursing note dated January 15, 2017 at 4:30 PM revealed that Patient #2 yelled for help, upon arrival to the room the patient was found on his knees. The patient was given an ice pack for the bruise on the knee.

A physician note dated January 15, 2017 at 6:05 PM, revealed "Patient describes mood as 'my arm is broken..."

Review of a nursing note dated January 16, 2017 revealed that Patient #2 complained of pain in the right shoulder after the fall. At that time an order was placed for a consult from the Nurse Practitioner regarding the shoulder pain, and the patient was given Tylenol. There were no additional evaluations or interventions documented with regard to Patient #2's shoulder.

A review of the "Master Treatment Plan" initiated on January 16, 2017 did not address falls, the need for fall precautions, and the possible side effects related to a new medication.

A nursing note dated January 17, 2017 at 6:30 PM revealed that Patient #2 was sent to the Emergency Department after his/her right shoulder and upper arm were "...extremely edematous and bruised with hematoma...", The note continued "...[outside hospital] are planning to operate on the patient because of the broken radius..."

Nursing staff failed to assess and create a care plan with interventions and measurable goals, to maintain the safety of Patient #2 and prevent future falls.

A face to face interview was conducted on March 13, 2017 at 11:34 AM with Employees #5 and 6 regarding the assessments of risks for falls, and maintenance of a care plan. Employee #5 stated that currently the facility does not have a fall scale and they are working on that process. However, they acknowledged that staff should have performed the assessments and incorporated risk for falls, and actual falls in the care plan.