HospitalInspections.org

Based on policy and procedure review, medical record review, and interview, it was determined the Behavioral Health Unit (BHU) at Northwest Medical Center failed to accept an appropriate transfer for 2 of 2 (#1 having homicidal ideations and #2 having a suicide attempt) patients requiring specialized psychiatric services not offered by the transferring facility related to (R/T) potential COVID-19 exposure and/or positive test results. By not accepting Patient #1 and Patient #2 the BHU delayed the specialized treatment needed for 2 of 2 (Patient #1 and Patient #2) patients with acute psychiatric conditions. The failed practice had the potential to affect any patient needing the specialized services provided by the BHU for acute psychiatric treatment. Findings follow:

A. Review of BHU policy and procedure titled: Admission Criteria Policy showed, "Conditions requiring continual IV therapy, medical work-ups, blood administration, or any type of isolation that would confine the patient to his/her room cannot normally be maintained on the inpatient Behavioral Unit."

B. Review of Northwest Medical Center Springdale policy titled: Guidelines for Direct Admits showed, "Hospital Facilities transferring patients to Northwest Springdale must obtain a COVID swab while the patient is at their facility. Patient cannot be transferred (unless deemed CRITICAL) until COVID results are confirmed."

C. Review of Patient #1 Continuum of Care Case Management Comments showed, "Patient refused admission at Northwest Medical BHU due to possible covid status mentioned in H and P (History and Physical). He has tested negative." Review of Immunology showed, "COVID-19 negative."

D. Review of Patient #2 Continuum of Care Case Management Comments showed, "Patient refused at Northwest Medical BHU due to possible covid status mentioned in H and P. He has tested positive, due to time past quarantine, still showing positive." Review of Emergency Documentation showed, "Patient does state that he was diagnosed with COVID-19 infection about 4-6 weeks ago but he was fully vaccinated with a JJ (Johnson and Johnson) vaccine prior to that. States that he is asymptomatic currently."

E. During an interview with BHU Director on 1/4/22 at 2:32 PM she stated that all patients admitted to the BHU are required to have a negative COVID-19 swab prior to admission to the BHU unit and that they were not accepting any patients that are COVID-19 positive.