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Based on policy review, census reports,closed medical record reviews and staff and physician interviews the hospital failed to comply with 489.24 by failing to provide stabilizing treatment within its capability and capacity for 1 of 6 sampled DED patients that were transferred with an emergency medical condition (#27).

The findings include:

~cross refer to 489.24(d)(1-3) Stabilizing Treatment Tag A2407

Based on policy review, Census reports,closed medical record reviews and staff and physician interviews the hospital's Dedicated Emergency Department (DED) failed to provide stabilizing treatment within its capability and capacity for 1 of 6 sampled DED patients that were transferred with an emergency medical condition (#27).

The findings include:

Review of the hospital's "Access to care in the Emergency Department" policy revised September 24, 2009 revealed "...2. Patient's are not denied evaluation, screening, testing, treatment, or stabilization on the basis of the ability to pay, race, creed, color, national origin, age, sex, or actual or perceived disability." Review of the hospital's "Emergency Medical Treatment and Active Labor Act (EMTALA)" policy effective August 24, 2000 revealed "...Stabilization: 1. When appropriate and within the capacity and capability of the hospital facilities and qualified personnel, any individual experiencing an EMC (emergency medical condition) must be stabilized prior to transfer or discharge, except as set forth in Item #3.... 3. An individual experiencing an EMC does not have to be stabilized: A. After being informed of the risks of transfer and the hospital's treatment obligations, the individual requests the transfer and signs a transfer request form; or B. Based on information available at the time of transfer, the medical benefits to be received at another facility outweigh the increased risk to the individual and a physician signs a certification to this effect, which includes a summary of the risks and benefits; or C. Based on the information available at the time of transfer, the medical benefits to be received at another facility outweigh the increased risk to the individual and, in the absence of a physician at the time of transfer, a QMP (qualified medical personnel), following consultation with the physician who has made the necessary determination, signs the certification which includes a summary of the risks and benefits...."

Review of the hospital's "Psychiatric Services Admission Criteria" effective January 1, 1986 revealed the criteria for admission included "Behavior which is life threatening, destructive, or disabling to self or others, Active suicidal or homicidal threats and debilitating depression." Further review revealed all requests for admission are evaluated for appropriateness on an individual basis based upon the patient's psychiatric history and current clinical information. The policy revealed that all inpatient admissions must be approved by a psychiatrist on the hospital's medical staff.

The facility's "Census Report-Detailed" dated 12/31/2009 and 1/1/2010 were reviewed. The section of this report titled and dated "____Psychiatric -Adult unit revealed that there were 8 vacant beds. On 1/1/2010 the _____ Psychiatric Adult unit had 7 vacant beds. The facility failed to ensure that stabilizing treatment was provided for patient #27 as evidenced by not admitting the patient. The facility had the capability and capacity on 12/31/2009 and 1/1/2010 to provide stabilizing treatment for patient #27.

Review of Patient #27's emergency department record revealed a 41 year-old female that presented to the hospital's dedicated emergency department (DED) on 12/31/2009 at 0151 with a chief complaint of "possible overdose." Review of nursing triage notes at 0151 recorded that "Patient states she took 20 5 mg (milligram) valium tablets and 16 unisom tablets about 1 hour ago. States SI (suicide ideation). 3 glasses of vodka and 1 beer." Review of a DED physician's note (dictated on 12/31/2009 at 0337) revealed a review of systems was completed with an impression of "major situational depression with suicide attempt, polypharmacy sedatives." Review of the physician's note revealed a plan to "Observe the patient carefully at this point. We have checked some labs. ...I am going to have a psychiatric consultant see her once her mental status improves. In the meantime, we have given her charcoal." Review of a DED physician's note (dictated on 12/31/2009 at 0711) recorded "...The patient wanted to leave but we told her she needs to talk to somebody this morning about her depression and suicide attempt. She is going over to the PEA (Psychiatric Evaluation Area)." Further review of the DED record revealed the patient was relocated to the Psychiatric Evaluation Area (PEA) at 0845 and was placed on suicide precautions with every 15 minute checks beginning on 12/31/2009 at 0845 through 01/01/2010 at 0045. Review of the record revealed a History and Physical examination completed by a nurse practitioner (dictated on 12/31/2009 at 1122) that documented "At the time of this note there is some question of disposition. To be admitted for inpatient treatment but likely not (name of hospital's psychiatric unit) at this time." Review of a social worker note dated 12/31/2009 at 0900 revealed Social Worker #1 had met with the patient for assessment. Review of the note recorded that the patient had "thoughts of suicide, plan: completed Self-destructive behavior. ...Danger to Self-Plan: overdose. ...Final Disposition: Consulted (Physician D - name of psychiatrist on staff at the hospital) and NP (MLP #1 - nurse practitioner) who concur with inpatient treatment. (Physician D) places patient on petition. (Name) with CSU (Crisis Stabilization Unit) reports that patient must remain in the ED (emergency department) 24 hours following an overdose. (Physician D) accepts patient for admission to (name of hospital's psychiatric unit). (Name) with (name of local management entity) refuses to provide authorization to (hospital's psychiatric unit) stating that there are no more beds remaining. Informed patient who reports an inability to pay and requests admission elsewhere." Further review of the record revealed a petition for involuntary commitment signed by the hospital's psychiatrist (no date or time when signed) that stated "Patient presents to (Hospital name) emergency department secondary to an overdose on #20 Valium 5 mg and #16 Unisom with suicide intent. Patient has no established outpatient providers. Patient is an imminent risk of harm to self and requires hospitalization for stabilization." Review of the "Certificate of Transfer" form revealed a check mark by a pre-printed statement that recorded "Treatment provided, including any necessary stabilizing treatment, to the extent possible within the resources and physician personnel available to our facility." The certification form revealed a pre-printed statement that had a check mark by "Reason for Transfer: for equipment or services not available at this facility (list)" with a handwritten note "bed availability." The certification form recorded benefits of transfer as "receive specialized treatment." Review of the form revealed the physician certification was signed by a nurse practitioner (MLP #2) on 01/01/2010 at 0045. Further review of the form revealed a pre-printed section for "Patient Consent to Transfer" with statements that were not checked. The patient signature area was handwritten "involuntary" and signed by a hospital social worker (Social Worker #1) on 12/31/2009 at 1800. The "Patient-Initiated Request for Transfer" section was blank. Record review revealed the patient was transferred via sheriff transport to a Crisis Stabilization Unit (CSU-B) on 01/01/2010 at 0059.

Review of Patient #27's medical record from CSU-B revealed the patient was admitted on 01/01/2010 for mood disorder. Review of the record revealed the patient was discharged on 01/03/2010.

Interview on 02/10/2010 at 1600 with psychiatric administrative staff revealed CSU-B was not an inpatient unit and not a hospital. The interview revealed the unit was not owned or operated by the hospital. Interview revealed the psychiatrists on staff at the hospital are also on staff at CSU-B. The CSU was described as a licensed crisis residential unit consisting of 16 beds with a maximum length of stay of 5-7 days.

Interview on 02/11/2010 at 1005 with hospital Social Worker #1 revealed she completed a psychiatric screening on Patient #27 and discussed her assessment with Physician D (psychiatrist). The staff member stated the patient needed admission and Physician D accepted the patient for admission to Hospital A's psychiatric unit. The interview revealed beds were available and the patient met criteria for admission. This interview was verified by review of the the facility's "Census Report-Detailed" dated 12/31/2009 -1/1/2010. The social worker stated "This patient had no health insurance. (Name of LME [local management entity]) is the HMO for the uninsured. We typically call insurance for approval and authorization of payment. The LME for our catchment area was notified because this patient did not have insurance." The staff member stated the LME said no beds were available at Hospital A's psychiatric unit and they would not authorize payment to Hospital A. The interview revealed the staff member informed the patient that the LME would not pay for admission to Hospital A and she would have to pay or she could go to another facility. The interview revealed the patient requested to go elsewhere because she did not want to pay. Interview revealed Physician D signed the petition for involuntary commitment "because CSU requires it for admission." The staff member stated that placement for the patient was "based on a need for psychiatric services and financial payment."

Interview on 02/11/2010 at 1145 with MLP #1 revealed she was a nurse practitioner that worked in the inpatient adult psychiatric unit and psychiatric evaluation area (PEA). Interview revealed the staff member had completed a history and physical on the patient in the PEA and determined that she was not appropriate for discharge and would need inpatient admission. The staff member stated the "admission and discharge process is between the intake screening staff (social worker) and the physician."

Telephone interview on 02/11/2010 at 1345 with MLP #2 revealed, she was the nurse practitioner who signed the certificate of transfer form for patient #27 on 01/01/2010 at 0045 for transfer to CSU-B. Interview revealed the patient was not a candidate for discharge home and was under petition for involuntary commitment. Interview revealed she signed the form after telephone consultation with Physician D. Interview revealed she only completes the signature blank. Interview revealed the risk and benefits, mode of transportation, and reason for transfer are already filled out by intake staff. Interview revealed Physician B did not co-sign the certification form for transfer.

Interview on 02/11/2010 at 1100 with Physician D (psychiatrist) revealed the crisis intervention unit is a 72 hour program that provides acute intensive services in a residential setting. The physician stated that the CSU does not provide the same level of care as inpatient treatment in a hospital setting. Physician D stated MLP #2 had consulted him regarding the information on the certification form. The interview revealed the physician was unaware that he needed to co-sign the certification form. The physician reviewed the certification form and stated that the information on the form documenting "no beds available" was incorrect. The physician revealed that beds were available in the hospital's psychiatric unit and the patient would be appropriate for admission. The physician stated "They (LME) thought this patient would be a better fit for CSU." The physician stated he did not see the patient and he thought the patient needed to be treated based on the assessment information from Social Worker #1 and MLP #2. The physician stated "They told me (name of LME) thought (CSU-B) was better for the patient. I went along with it. We did not talk about beds available." Interview with the physician revealed psychiatric services could have been provided in the hospital's inpatient psychiatric unit.

Interview on 02/11/2010 at 1310 with psychiatric unit administrative staff revealed the hospital's psychiatric unit had capacity to admit patients on 12/31/2009 with a census of 10 patients on 5N with 16 staffed beds and a census of 14 patients on 5S with 15 staffed beds. The interview revealed 5N had availability on 01/01/2010 with a census of 8 patients and 16 staffed beds. Interview revealed the hospital's psychiatric unit had capacity and capability to admit Patient #27. The interview revealed the patient met criteria for admission and the psychiatrist had agreed to admit the patient to the hospital's psychiatric unit. The interview revealed the patient was transferred to the Crisis Stabilization Unit after the LME said that there were no beds available at the hospital's psychiatric unit that would be paid for.

NC00062131