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Based on record review and interview, facility staff failed to accept the transfer of 1 of 20 patients with an emergency medical condition who required inpatient psychiatric treatment (Patient #1).

Findings include:

Facility staff failed to accept a transfer of a patient requiring inpatient psychiatric treatment. See tag A2411.

Based on record review and interview, facility staff failed to accept the transfer of 1 of 20 patients with an emergency medical condition who required inpatient psychiatric treatment (Patient #1).

Findings include:

Review of the facility's services revealed the facility is a mental health provider. Per the facility's website: "[Facility] serves children and adults court-ordered into inpatient psychiatric assessment treatment through county-based emergency detention and commitment proceedings."

Review of facility policy "203.02 Admission Medical Clearance" dated 10/2017 revealed "For adults: [Facility] requires 'medical clearance' before allowing admission to the Institute under emergency detention. ...Medical clearance is required for all adult emergency detentions. Medical clearance may be requested on any potential admission, regardless of age, as deemed appropriate by physician/nursing supervisor. ...Medical clearance includes: 1. Assessment of vital signs, 2. A brief physical assessment, 3. CBC, Chem Panel, UA [urinalysis], and drug screen (toxicology is requested if patient has or is suspected of overdosing). ...NOTE: Medical clearance is determined by a physician who may request additional information and/or labs. Depending on circumstances physician may approve admission without above stated medical clearance information. Admission of a person with a complicated medical condition will be allowed on a case-by-case basis based on the needs of the patient and [the facility's] ability to meet those needs."

Review of the referring Emergency Department [Hospital H] physician progress notes dated 9/24/2018 revealed Patient #1 presented to Hospital H's Emergency Department in police custody in an emergency hold for mental health. "[Patient #1] here for medical clearance while [county crisis] is looking for mental health placement. ...As best I can with [#1's] lab refusal I think [#1] is medically clear. There is no intoxicant on urinalysis, vital signs are unrevealing and physical exam is unrevealing. [#1] voices no medical concerns although clearly [#1] minimizes mental health concerns. Awaiting mental health placement."

Review of the facility's "Preadmission Screening Assessment" for Patient #1 dated 9/24/2018 revealed "Legal Status: 72 hour Detention (51.15). Security: Yes--Elopement Risk. Psychiatric: Yes--History of AODA. Level of Severity: Yes--Aggression Toward Others or Objects, Yes--Suicide Risk, Yes--Trauma History. Diagnosis/Reason for Referral: Schizophrenia/SI [suicidal ideation] and HI [homicidal ideation]." The form documented a projected admission date of 9/25/2018. Under a description of precipitating events: "Per family, [#1] was having multiple personalities, one of which threatened to kill members of the family as well as [self]. ...refused to talk to crisis and is very paranoid. ...expressed SI to crisis. ...AODA History: Per [family member], history of alcohol and meth use. No use today or yesterday." Requested goals for treatment from the referring county included "Mental health assessment, medication evaluation and recommendation, stabilization, psych evaluation."

During an interview on 10/16/2018 at 9:00 AM, Medical Director A stated Hospital H referred Patient #1 to the facility on 9/24/2018 and "we asked them to complete a medical clearance. We have a medical clearance sheet which lists everything we ask for." When asked if there is a standard, accepted definition of what components are required to obtain medical clearance, Medical Director A, "medical clearance is what we feel we need... we don't have the capacity to treat acute medical illnesses."

During an interview on 10/16/2018 at 9:15 AM, Deputy Director B stated Patient #1 arrived at the facility from Hospital H on 9/25/2018. Deputy Director B stated that "when the patient got here, [Nursing Supervisor P] informed the ambulance that the patient could not be admitted because medical clearance had not been obtained." Deputy Director B stated Patient #1 was not admitted to the facility.

During an interview on 10/16/2018 at 11:10 AM, Admissions Coordinator D stated "if a patient refuses medical clearance, we try to set up a doctor to doctor phone call to see if they can be waived." During an interview on 10/16/2018 at 2:15 PM, Admissions Supervisor E stated when additional information is needed [prior to accepting a patient] "there's usually a doctor to doctor phone call to make that determination." Per Medical Director A, the facility had 2 different providers (Physician Assistant G and Physician C) speak directly with the physicians at Hospital H and both denied acceptance of Patient #1 without lab work.

During an interview on 10/16/2018 at 12:55 PM, Physician C stated C was willing to accept the transfer of Patient #1 pending lab results. Per C, "I talked with the ED physician [from Hospital H] in the morning... There are a number of medical conditions that can contribute to psychiatric symptoms... out of range TSH [thyroid stimulating hormone], or calcium levels, even blood sugar. This patient was homeless and a regular drinker, had an elevated blood pressure, I was concerned about detox." When asked if lab work would reveal Patient #1's detox status, Physician C stated "they would not."

During an interview on 10/16/2018 at 3:35 PM, Supervisor E stated "we don't refuse admissions. We are the state's psychiatric 'safety net' we just try to make sure it's safe for patients to be here." Medical Director A stated the decision to accept Patient #1 was at the discretion of the admitting medical provider. The facility did not accept the transfer of Patient #1 and there was no evidence that facility staff considered accepting Patient #1 without lab work or that the physician to physician contact between referring and recipient hospitals was effective in meeting Patient #1's identified needs for psychiatric care.