HospitalInspections.org

15036

Based on interview, record review, medical staff by-law review, and policy review, the hospital failed to meet the Conditions of Participation (CoP) for Governing Body (GB) when it failed to ensure:
*One of one qualified mental health professional (QMHP) who conducted mental health evaluations for hospital patients was reviewed by the hospital's credentialing committee.
*Discharge protocols implemented under the direction of legal counsel did not include jail or going to other non-health care facilities for patients diagnosed with psychiatric illnesses.
*Protocols implemented on 2/1/17 for the discharge and transfer of patients diagnosed with psychiatric illness, who were on an involuntary hold, and meeting commitment criteria, had been approved by the governing body.
Findings include:

1. Review of the provider's March 31, 2016 Bylaws of the Medical Staff, Rules and Regulations, and the Appendix of the Medical Staff revealed:
*"Certain health professionals who are not either physicians or dentists may be granted privileges as recommended by the Medical Executive Committee and approved by the Board."
*"Such health professionals shall be called "advanced practice professionals."
*"Only advanced practice professionals who hold a license, certificate, or any other legal credential required by State law; are qualified by training, background, experience and competence in a health discipline the Board has determined by policy to allow to practice in the hospital..."
*Medical staff and advanced practice professional (APP) should have been reviewed by the facility's credentialing committee prior to providing care to hospital patients.
*The two categories of APP were allied associates and allied assistants.
*Psychiatric social workers were considered allied assistants.

Interview on 2/21/17 at 2:40 p.m. and again on 2/22/17 at 8:32 a.m. with the director of the emergency department (ED) and the manager of the ED pertaining to a new protocol regarding mental health patients presenting to the ED revealed:
*In a meeting with the department directors and/or managers approximately two weeks before 2/1/17 they had been told there was going to be a new process and criteria for behavioral health admission.
*They were given no new policy or new guidelines to follow for that new process.
*They had been told by administration "We have been told by legal [provider's general counsel] this is going to happen as of 2/1/17."
*Administration did not put any formal procedure or plan in place prior to the change on 2/1/17.
*The basic plan would have been to discharge the patient on a mental health hold from the ED to the jail if there was no post-discharge plan in place. The QMHP would have evaluated the patient in jail if needed.
*Upon notice from administration and the provider's general counsel the ED director had created her own behavioral health capacity communication plan.

Interview on 2/22/17 at 10:30 a.m. with the interim president of the hospital and the director of quality, safety, and risk management revealed the QMHP was not required by state law to be credentialed.

Interview on 2/22/17 at 11:10 a.m. with the county QMHP regarding patients on emergency mental health holds revealed:
*She was a contracted employee of the County and was responsible for evaluating patients on involuntary mental health holds to determine if they met the criteria for commitment.
*She was not an employee of the hospital or contracted by the hospital.
*She had met all criteria required for licensing and education to be a QMHP.

Interview on 2/22/17 at 4:38 p.m. with the director of quality, safety, and risk management confirmed:
*There was no contract or agreement with the county for the QMHP conducting mental health evaluations for hospital patients.
*There was no job description for the county QMHP.

Refer to A338, finding A1.

Refer to A338, finding B1; and A1100, finding 1 and 2.

15036

A. Based on interview and By-laws of the Medical Staff review, the provider failed to ensure:
*One of one qualified mental health professional (QMHP) was credentialed to perform mental health evaluations for all psychiatric patients placed on an involuntary mental health hold.
*There was a written agreement or contract for services provided by one of one QMHP that performed mental health evaluations for all patients placed on an involuntary emergency mental health hold.
Findings include:

1. Interview on 2/22/17 at 10:30 a.m. with the interim president of the hospital and the director of quality, risk management, and safety revealed the QMHP was not required by state law to be credentialed.

Interview on 2/22/17 at 11:10 a.m. with the county QMHP regarding patients on emergency mental health holds revealed:
*She was a contracted employee of the county and was responsible for evaluating patients on involuntary mental health holds to determine if they met the criteria for commitment.
*She was not an employee of the hospital or contracted by the hospital.
*She had met all criteria required for licensing and education to be a QMHP.

Interview on 2/22/17 at 4:38 p.m. with the director of quality assurance, risk management, and safety confirmed there was no contract or agreement with the county for the QMHP conduction mental health evaluations for hospital patients nor a job description.

Review of the provider's 3/31/16 Bylaws of the Medical Staff revealed:
*"Certain health professionals who are not either physicians or dentists may be granted privileges as recommended by the Medical Executive Committee and approved by the Board.
*Such health professional shall be called "advanced practice professionals." Only advanced practice professionals who hold a license, certificate, or any other legal credential required by State law; are qualified by training, background, experience and competence in a health discipline the Board had determined by policy to allow to practice in the hospital; meet other qualifications required by the hospital; and who on the basis of documented references, adhere to the ethics of their profession; work cooperatively with others; and participate as appropriate in the quality review, evaluation and monitoring activities required, and in the discharge of other required responsibilities, may be granted advance practice professional status."
*Psychiatric social workers were listed as allied assistants and requirements included:
-A current state license by the Board of Social Work Examiners as a certified social worker.
-Possessed a doctorate or master's degree from a school of social work accredited by the Council on Social Work Education.
-Had a minimum of two years supervised experience in a psychiatric setting.
-Employment or supervision by a physician member of the Active or Associate Medical Staff who agreed to be responsible for the psychiatric social worker.
*Initial applicants must have submitted:
-An application.
-A hospital approved agreement signed by the supervising medical staff.
-A completed list of privileges.
-Evidence of a current license.
*Reappointment applicants must have submitted all required documentation required by the credentialing committee.
*Reappointments were conducted bi-annually.
*Qualifications, responsibilities, and oversight of the county QMHP were not addressed.

B. Based on interview, Bylaws of the Medical staff review, and policy review, the provider failed to ensure:
*Protocols developed and implemented for discharge and transfer of patients diagnosed with a psychiatric illness, who were on an involuntary hold, and meeting commitment criteria, were not transported to jail or other non-health care related facilities when the Behavioral West unit was at full capacity.
*Protocols implemented for the discharge and transfer of patients diagnosed with psychiatric illness, who were on an involuntary hold, and meeting commitment criteria, had been approved by the governing body.
Findings include:

1a. Interview on 2/21/17 at 2:40 p.m. and again on 2/22/17 at 8:32 a.m. with the director of the emergency department (ED) and the manager of the ED regarding mental health patients presenting to the ED revealed:
*It was now their understanding that acute medical care (inpatient tower) did not take care of mental health/psychiatric patients.
*As of 2/1/17 the patients in the tower now had a physiological condition but not a mental or psychological condition.
*Once a patient was discharged from the ED and off the provider's campus the patient was no longer the provider's responsibility.
*If there was no plan in place the patient might go to jail.
*Prior to the new process there had been no safety issues in the patient tower with mental health patients or the provider's staff that they could remember.
*In a meeting with the department directors and/or managers approximately two weeks before 2/1/17 they had been told there was going to be a new process and criteria for behavioral health admission.
*They were given no new policy or new guidelines to follow for that new process.
*They had been told by administration "We have been told by legal [the provider's general counsel] this is going to happen as of 2/1/17."
*Administration did not put any formal procedure or plan in place prior to the change on 2/1/17.
*The basic plan would have been to discharge the patient on a mental health hold from the ED to the jail if there was no post-discharge plan in place. The QMHP would have evaluated the patient in jail if needed.
*Upon notice from administration and the provider's general counsel the ED director had created her own behavioral health capacity communication plan.
*They had not completed any tracking or trending of the new process since it was initiated.
*They had done a group and one-on-one notification of the new process for mental health patients on a hold, but they agreed there were still employees that had not been notified of the new process.
*They had not tracked the training with the ED employees as the process had happened very quickly.

b. Interview on 2/22/17 at 9:20 a.m. with the medical director of the ED revealed:
*Late last fall 2016 he had heard that the provider wanted criteria for a mental health admission to the hospital. The problem appeared to have been space for mental health patients in the hospital.
*He thought it was a financial/administrative perspective of "How can we detour those patients who were intoxicated from admission to the hospital."
*Financial concerns made the decision to put the process in place.
*Administration did not involve those staff who were going to be directly involved in the process, i.e. ED staff. Administration stated "We have been told by legal [provider's general counsel] this is going to happen as of 2/1/17. The process was birthed through individuals not involved in direct patient care."
*He understood the new process was:
-ED would admit the patients.
*Involuntary holds would typically come into the ED.
-With an involuntary hold a QMHP would have twenty-four hours to evaluate the patient for emergency commitment or removal of the hold when in the ED.
-While in the ED "they [patients] are the responsibility of the hospital."
-The county QMHP had to either certify the hold or remove the hold.
-If the hold was removed by the QMHP the facility's Transfer Center would attempt to get the patient to another treatment facility.
-"The crisis care center absorbs much of the mental health patients now."
-His department was given a verbal process from administration, but he had never seen anything written down.
-"Mental health issues are medical issues. Any patient coming to the ED is an emergency. Mental health has been separated out from a medical condition."

c. Interview on 2/22/17 at 10:30 a.m. with the provider's interim president revealed:
*"We started this process in accordance with state law."
*When the behavioral health center was full, those mental health patients on a mental health hold would have been transferred to the jail.
-"We would like the county to take responsibility for the patient."
-"We could no longer take the risk of safety for the patients and staff in the patient tower."
-There had been no safety incidents that had happened in the tower to either mental health patients or to the staff.
*"When we are full the county needs to take responsibility."
*When the patient was discharged from the ED the county was responsible for that patient.
*The QMHP determined the patient was either committed (admitted) or not (hold removed).
*While still in the hospital the county made the determination where the mental health patient would go.
*"We offered the Transfer Center service to assist the county with placement of the mental health patient."
*"What we are doing is in accordance with state law."

d. Interview on 2/23/17 at 8:00 a.m. with the county sheriff and chief deputy regarding mental health patients seen in the hospital ED revealed:
*The sheriff's department had received a letter from the local hospital dated 1/23/17 prior to the initiation of the new process at the hospital. The new process was related to mental health patients brought to the ED on a mental health hold or placed on a mental health hold during the ED visit.
*The sheriff thought the change in the process had been related to availability of hospital beds, staffing issues, and behavioral health was not profitable for the hospital.
*The hospital's attorney had come to the jail on January 20, 2017 to inform the sheriff about the new process scheduled to have been initiated on February 1, 2017.
*The new process was mental health patients who were on mental health holds would have been transferred to the jail once those individuals had been medically cleared.
*Then on January 26, 2017 the sheriff had received a letter from Rapid City Regional Hospital regarding the hospital's intention to initiate the new process of transferring mental health patients on holds to the jail.
*On January 30, 2017 the sheriff's office and the hospital had met, but it was evident the hospital representatives had not come to negotiate on the new process.
*There was no statute that stated the county was responsible for mental health patients.
*The statute only allowed the jail to keep the mental health patients on mental health holds for twenty-four hours, and then the jail had to release those individuals.

Review of the provider's March 31, 2015 Bylaws of the Medical Staff Rules and Regulations of the Medical Staff and Appendix revealed:
*"Clinical practice protocols and guidelines provide guidance in the medical and nursing management of specific patients and are based on evidence-based practice. The goal of these protocols and guidance is to improve patient outcome by utilizing best practice recommendations.
*The following criteria will be utilized in the selection and development of clinical practice protocols and guidelines:
-High variability in practice patterns
-Opportunity for improvement in practice
-Support and interest of physicians
-High volume, high risk and/or high cost
*The development of a clinical practice protocol will be accomplished through a multidisciplinary team with oversight by the Medical Staff member champion(s). A designated "owner" of the protocol shall be identified and will be responsible for coordinating the development, review, revision and staff education regarding the protocol.
*Clinical practice protocols shall be reviewed at pertinent Medical Staff department meetings or with the designated medical department chair for approval prior to implementation.
*Approved clinical practice protocols and guidelines shall be reviewed every two years or more frequently to accommodate changes in standards of practice and care."

Review of the provider's October 2014 Discharge with Transfers: Another Facility and Intracorporation (Rehab, Behavioral Health) policy did not address the new process implemented on 2/1/17.

Review of the provider's November 2014 Emergency Treatment and Labor Act (EMTALA) Medical Screening Examination, Stabilization, Treatment and Transfer policy revealed:
*"H. Discharge: A patient is considered stable for discharge (vs. transfer) when, within reasonable clinical confidence, it is determined the patient has reached the point where his/her continued care, including additional diagnostic work-p [work-up] and/or treatment, could reasonably be performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with discharge instructions."
*The policy did not address when the behavioral health unit was at capacity:
-The hospital's current process was to call the county sheriff's office so they could assume responsibility for that patient.
-It was the county's responsibility to find appropriate treatment facilities for patients with psychiatric conditions.

Review and comparison of the provider's August 2015 and updated February 2017 Admission Criteria, Inpatient policy revealed:
*The policies did not address when the Behavioral Health unit was at capacity:
-The provider's current protocol implemented on 2/1/17 included calling the county sheriff's office for them to assume responsibility of the patient.
*It was the county's responsibility to find appropriate treatment facilities for patients with psychiatric conditions.

30170

Based on interview, record review, and policy review, the provider failed to ensure appropriate policy and procedures were in place to address all patients who had presented to the emergency department (ED) for treatment of a psychiatric emergency. Findings include:

1 a. Interview on 2/21/17 at 2:40 p.m. and again on 2/22/17 at 8:32 a.m. with the director of the ED and the manager of the ED regarding mental health patients presenting to the ED revealed:
*It was now their understanding acute medical care (inpatient tower) did not take care of mental health/psychiatric patients.
-The mental health patient was evaluated for a medical condition (infection, illness, or injury).
-Then the mental health patient might have been admitted to the intensive care unit or patient care unit.
-They would have received one-on-one observation in those units.
*As of 2/1/17 the patients in the tower now had a physiological condition but not a mental or psychological condition.
*Once a patient was discharged from the ED and off the provider's campus the patient was no longer the provider's responsibility.
*If there was no plan in place the patient might go to jail.
*They did not know the condition of the patient after discharge from the ED.
*They did not know if the patient was safe at the jail. They were no longer responsible, and the patient was now the responsibility of the county.
*When the provider's Transfer Center found a "bed" (place) for the involuntary mental health patient it might have been the crisis care center or the city/county alcohol and drug program.
*The Transfer Center was a courtesy provided by the hospital.
-"It's a courtesy to attempt to find placement for the mental health patient after discharge from the ER [emergency room] to the jail."
*"Mental patients coming to the ED are in a crisis. Going to jail doesn't facilitate their treatment."
*Prior to the new process there had been no safety issues in the patient tower with mental health patients or the provider's staff that they could remember.
*In a meeting with the department directors and/or managers approximately two weeks before 2/1/17 they had been told there was going to be a new process and criteria for behavioral health admission.
*They were given no new policy or new guidelines to follow for that new process.
*They had been told by administration "We have been told by legal [provider's general counsel] this is going to happen as of 2/1/17."
*Administration did not put any formal procedure or plan in place prior to the change on 2/1/17.
*The basic plan would have been to discharge the patient on a mental health hold from the ED to the jail if there was no post-discharge plan in place. The QMHP (qualified mental health professional) would have evaluated the patient in jail if needed.
*They had not completed any tracking or trending of the new process since it was initiated.
*They had done a group and one-on-one notification of the new process for mental health patients on a hold, but they agreed there were still employees that had not been notified of the new process.
*They had not tracked the training with the ED employees as the process had happened very quickly.

b. Interview on 2/22/17 at 8:00 a.m. with the director and clinical nurse of behavioral west unit revealed:
*They were made aware of the new process at a 12/7/16 meeting with the provider's legal department.
*They had a department meeting on 1/18/17 to let staff know about the changes in the new process. Not all of the staff were notified because some had been on leave.
-Review of the 1/18/17 department meeting minutes revealed:
"2. Change in Admissions - February 1 there will be a change in patients that will be admitted to [psychiatric facility]. We will be restricting dementia and diagnosed autistic patients. We are also working toward no overflow to the towers [inpatient rooms at the main hospital]. The affected community will be notified by letters regarding these changes."
*Adolescents were on a one-to-one floor. If a suicidal ideation adolescent patient needed admission from ED and there was no bed at the psychiatric hospital:
-They would have let the Transfer Center and ED know there was no room.
-Transfer Center would have notified the county.
-QMHP would evaluate the ED physician's decisions.
-The QMHP made the "safe plan."
-The ED physicians could request a consult from one of the psychiatrists at the psychiatric hospital.

c. Interview on 2/22/17 at 8:32 a.m. with the director of the ED revealed upon notice from administration and the provider's general counsel she had created their departments own behavioral health capacity communication plan. Review of that undated plan revealed:
*When Behavioral Health was at capacity:
-The on call Transfer Center then called [city name] dispatch to inform law enforcement that they were full and would not accept additional behavioral health patients.
*When a bed opened at Behavioral Health:
-If no patients were holding in the [hospital name] inpatient/ED area, the on call Transfer Center called dispatch to inquire if law enforcement was holding any behavioral health patients, and notified them they now had open beds.
*If a new behavioral health patient arrived while the Behavioral Health unit was at capacity, the on call Transfer Center initiated the checklist of Behavioral Health patients.
*Transfer Center Process/Communication when the behavioral health unit was at capacity:
-If they received a call from a clinic in [city name] or elsewhere and there was no bed available for the patient they were to have stated that, "Behavioral Health is at full capacity and they will need to call local law enforcement to have them take custody of the patient."

d. Interview on 2/22/17 at 9:20 a.m. with the medical director of the emergency department revealed:
*Late last fall 2016 he had heard the provider wanted criteria for a mental health admission to the hospital. The problem appeared to have been space for mental health patients in the hospital.
*He thought it was a financial/administrative perspective of "How can we detour those patients who were intoxicated from admission to the hospital."
*Financial concerns made the decision to put the process in place.
*Administration did not involve those staff who were going to be directly involved in the process, i.e. ED staff. Administration stated "We have been told by legal [provider's general counsel] this is going to happen as of 2/1/17. The process was birthed through individuals not involved in direct patient care."
*He understood the new process was:
-ED would admit the patients.
-Involuntary holds would typically come into the ED.
-With an involuntary hold a QMHP would have twenty-four hours to evaluate the patient for emergency commitment or removal of the hold when in the ED.
-While in the ED "they [patients] are the responsibility of the hospital."
-The county QMHP had to either certify the hold or remove the hold.
-If the hold was removed by the QMHP the facility's Transfer Center would attempt to get the patient to another treatment facility.
-"The crisis care center absorbs much of the mental health patients now."
-His department was given a verbal process from administration, but he had never seen anything written down.
-"Mental health issues are medical issues. Any patient coming to the ED is an emergency. Mental health has been separated out from a medical condition."

e. Interview on 2/22/17 at 10:30 a.m. with the provider's interim president revealed:
*"We started this process in accordance with state law."
*When (behavioral health center) was full, those mental health patients on a mental health hold would have been transferred to the jail.
-"We would like the county to take responsibility for the patient."
*We could no longer take the risk of safety for the patients and staff in the patient tower.
-There had been no safety incidents that had happened in the tower to either mental health patients or to the staff.
*"When we are full the county needs to take responsibility."
*When the patient was discharged from the ED the county was responsible for that patient.
*The QMHP determined the patient was either committed (admitted) or not (hold removed).
*While still in the hospital the county made the determination where the mental health patient would go.
*"We offered the Transfer Center service to assist the county with placement of the mental health patient.
*What we are doing is in accordance with state law."

f. Interview on 2/22/17 at 11:10 a.m. with the QMHP revealed:
*She was an employee of the county.
*She did not have a contract with the hospital nor was she credentialed by the hospital.
*She had been told she would evaluate all patients who had been delivered to the ED by local law enforcement. The county was responsible for:
-A QMHP.
-A hearing officer.
-Transportation to another facility.
*She stated an emergency commitment hold would have been admitting the patient to a psychiatric medical facility. The closest regional (in area) psychiatric hospital would have been the local hospital.
*If the patient did not meet the mental health guidelines according to state law she would have removed the patient from the hold, and they would have been released.
*It was not her decision where the patient would have been transported to after the removal of the hold and released from ED.
*The Transfer Center would work with authorities to transfer the patient to another acute care facility.
*She did not determine the disposition of the patient. She determined if they met the criteria of an involuntary hold or removal of the hold.
*Prior to October 2016 all mental health patients went to the psychiatric unit and received QMHP evaluations. After October 2016 all psychological evaluations went through the ED.
*She had been told the change was due to a lot of mental health patients in the ED were discharged within twenty-four hours and were not admitted.
*It was her understanding it was a financial decision made by administration.

g. Interview on 2/22/17 at 11:30 a.m. with the director of the Transfer Center revealed:
*The Transfer Center was part of the hospital.
*All ED patients and inpatients went through the Transfer Center.
*If the patient presented to the ED involuntarily the QMHP would evaluate that patient.
*The health unit clerk placed a request for a bed in the system to see if a bed was available or unavailable.
-If no bed was available the voluntary mental health patients would have been held in the ED until a treatment could have been initiated.
*If the patient had been evaluated by the QMHP the county was responsible to get the patient continued care if needed.
*When the mental health patient was turned over to the county they would have had the decision to transport to another acute care facility, or to have taken the patient back to jail.
-She revealed "I think the patient is safe in jail. But I don't think they are getting the treatment they need."
*The Transfer Center only dealt with continued acute patient treatment to other providers.
*The Transfer Center was directed by the provider's general counsel to contact the county to "ask what they want to do with the patient."
*"The patient in the ED was the responsibility of the hospital, and mental health issues were considered a medical emergency."
*There was no policy for the new process; it was only a process change.
*The provider's legal department had created the 1/18/17 procedural checklist and flow chart.
-Review of the above dated flow chart revealed:
-"Patient arrives on a hold, or hold was placed = NO".
-Case management and Transfer Center would assist with community resources and D/C (discharge).
-Review of the above dated checklist of behavioral health patients revealed:
-1. Verify that there was no bed at Behavioral Health.
-2. If no bed was available at Behavioral Health unit then call law enforcement.
-Ask "would you like us to attempt to find another facility to transfer the patient to or would you like to take custody of the patient."
-3. Start calling other facilities that law enforcement had agreed to transport to.
-4. If another facility had accepted the patient then contact law enforcement.
-If no accepting facility contact law enforcement to take custody of the patient.
-5. If the county was unwilling to take the patient or there were other issues the hospital coordinator would be contacted, and decisions would be made by the administrator on-call.

h. Interview on 2/22/17 at 12:30 p.m. with the masters in social work (MSW) revealed:
*In the ED the QMHP would make the decision to see if the temporary hold should remain in place or if it could be removed.
*The QMHPs job was not to make the decision of the disposition of those patients.
*It was the hospital's responsibility to find a disposition for the patient.
*"If our facility was full the patients would have either gone to the crisis center or to another provider".
*There should have been a safety plan or contract in place to keep the patient safe.

i. Interview on 2/23/17 at 8:00 a.m. with the county sheriff and chief deputy regarding mental health patients seen in the hospital ED revealed:
*The sheriff's department had received a letter from the local hospital dated 1/23/17 prior to the initiation of the new process at the hospital. The new process was related to mental health patients brought to the ED on a mental health hold or placed on a mental health hold during the ED visit.
*The sheriff thought the change in the process had been related to availability of hospital beds, staffing issues, and behavioral health was not profitable for the hospital.
*Jail was not the appropriate place for those individuals with mental health conditions.
*He stated a mental health emergency should have been treated just like a medical condition emergency.
*There needed to have been more bed availability for mental health patients.
*He felt as though there would have been a delay in treatment for those mental health patients if they were admitted to the jail. Jail was not the place for individuals with mental health conditions.
*There were no twenty-four hour nursing services available at the jail. A nurse was available from 6:00 a.m. until 10:00 p.m. at night.
*The hospital's attorney had come to the jail on January 20, 2017 to inform the sheriff about the new process scheduled to have been initiated on February 1, 2017.
*The new process was mental health patients who were on mental health holds would have been transferred to the jail once those individuals had been medically cleared.
*Then on January 26, 2017 the sheriff had received a letter from the local hospital (provider) regarding the hospital's intention to initiate the new process of transferring mental health patients on holds to the jail.
*On January 30, 2017 the sheriff's office and the hospital met, but it was evident the hospital representatives had not come to negotiate on the new process.
*There was no statute that stated the county was responsible for mental health patients.
*The statute only allowed the jail to keep the mental health patients on mental health holds for twenty-four hours, and then the jail had to release those individuals.
*On February 1, 2017:
-The county dispatcher had been contacted by the hospital's Transfer Center to come and pick up a mental health patient from the ED. The Transfer Center had told the dispatcher "We have a patient, no beds, and to come and pick them up."
-The dispatcher had notified the chief deputy, and the chief deputy declined the request.
-The hospital's general counsel called the chief deputy at 11:00 p.m. that night in regards to the above incident and why the ED patient had not been taken into custody by the county.
*The jail did not have the resources necessary to effectively triage mental health individuals. The cells were set-up for inmates not psychiatric patients.
*The jail staff were not monitoring mental health individuals every fifteen minutes, the jail staff would monitor the mental health individuals on holds approximately every thirty minutes.
*"We shouldn't criminalize mental health. The jail is not the right care for mental health people. For over three decades [hospital name] has been the appropriate regional [in area] facility."

j. Interview on 2/23/17 at 9:05 a.m. with the vice-president of Quality Assurance and Risk Management revealed there was nothing specific in the provider's July 2015 EMTALA (emergency medical treatment and labor act) policy for mental health.

k. Review of a 1/23/17 letter from the hospital interim president to the chairman of the county board of mental health, the county sheriff, and the chief of police revealed:
*"I write to inform you of changes to the admission criteria at [provider]. Effective February 1, 2017, we will no longer admit behavioral health patients who do not have acute medical needs to the main hospital when the [psychiatric facility] is at capacity. We will expect the County to take custody of patients who are subject to the involuntary mental commitment process, pending an opening at the [psychiatric facility]. It is simply no longer feasible for us to care for behavioral health patients who do not have acute medical needs outside of the [psychiatric facility]. We will contact the Sheriff's office to take custody of involuntarily detained person when the [psychiatric facility] is at capacity.
Also, by way of information, we will no longer admit patients to the [psychiatric facility] who have neurodevelopmental/cognitive disorders such as dementia, Alzheimer's disease, or autism spectrum disorders. We believe it is in the best interest of all patients to limit the conditions which are appropriate for the treatment in our facility."

l. Review of the February 15, 2017 Emergency Medicine meeting minutes revealed "Psych to tower will not admit psychiatric admits to tower unless there is a medical reason. Meeting next week to discuss."

Review of the November 16, 2016 Emergency Medicine meeting minutes revealed:
*"As of October 1 will not allow patients to go to [name of behavioral health unit] unless their hold has been certified. QMHP has a 2 hour response time. Has shared concerns with [System COO name].
*50% of mental health holds were being released within 24 hours.
*Fewer ED to crisis care center patients in October, more law enforcement to crisis care center. 25-30% reduction in holds to [name of the behavioral health unit]."

m. Review of the 1/11/17 Pt [patient] Flow Meeting minutes revealed "Psych admission criteria is changing. There is a subgroup working on this process and the effect it can have on the ED and inpatient areas."

Review of the 2/15/17 Pt Flow Meeting minutes revealed:
*"Admission criteria changes have occurred.
*ED [emergency department]/TC [transfer center] will track future patients that are held or transferred to another facility.
*Psych will no longer be tracking this information."

2. Review of an additional undated checklist of behavioral health patients revealed:
*"1. Is there a bed at [psychiatric facility]?
-1. c. if no bed expected within a couple of hours go to step 2.
*2. Start calling other facilities within South Dakota to arrange transport.
*3. Call County to take custody of patient. They will either transfer to accepting facility or jail.
*4. If the county is unable to transport the patient to an accepting facility, contact [city fire department] for transport.
*6. If the county is unwilling to take, call ED Administration on-call."

Review of the provider's March 2014 Identification of Psychosocial Issues on Initial Assessment policy revealed:
*The policy statement was intended to have addressed the needs of patients with psychosocial issues identified during the initial assessment in the ED.
*All patients would have been triaged upon arrival in the ED.
*Any patient identified with psychosocial issues during the initial assessment would have the proper referral initiated.
*Resources included:
-Psychiatric services.
-Infection control.
-Law enforcement.
-Social services.

Review and comparison of the provider's August 2015 and updated February 2017 Admission Criteria, Inpatient policies revealed:
*Statement
-2015 and 2017: "Define, evaluate, and treat major psychiatric illness including disorders of thought, mood, and behavior for medically stable patients who would benefit from a therapeutic environment. Psychosocial evaluation with appropriate intervention and follow up is done where possible."
--2017 Addition: "The unit does not accept patients with neurodevelopmental/cognitive disorder such as dementia, Alzheimer's, Autism Spectrum disorder (ASD)."
*Guidelines:
-2015 and 2017: "A. The decision to admit to Behavioral Health was the responsibility of the physician. Patients needing acute Behavioral Health inpatient services were defined as those who required twenty-four hour skilled psychiatric nursing care and were not able to function independently or with reasonable assistance in a less restrictive or outpatient environment."