HospitalInspections.org

Based on review of policies and procedures, review of clinical records, review of hospital documents and staff interviews, it was determined:

1. For 3 of 9 records reviewed of patients who presented to their Care Center as a "walk-in," the hospital failed to fulfill their obligation to perform a Medical Screening Examination (MSE) following their policies and protocols to determine whether or not an emergency medical condition exists. This deficient practice poses the risk of medical and/or psychological emergencies not identified and addressed. (Patients #1, #3, #4.)

2. The "Admission Packet" provided to all patients who presented to their walk-in Care Center for psychiatric treatment included statements which may deter the patient from staying and receiving a medical screening examination.

Findings include:

1. The hospital's Policy and Procedure titled, "EMTALA" revision date 7-2019 included the following: "Valley Hospital shall follow all of the federal regulations regarding treating emergency medical conditions...Valley Hospital has a duty to follow the EMTALA regulations for hospitals with a Dedicated Emergency Room...1. At a behavioral hospital, the Intake/Assessment and referral center is a DED. EMTALA applies to anyone who presents on hospital property stating he/she has an Emergency Medical/Psychiatric Condition. 2. The hospital MUST screen the patient and treat the patient until the resolution of the emergency medical condition or the patient is stabilized and transferred to a more appropriate level of care...4. An Emergency Medical Condition (EMC) is defined as a condition which a 'prudent layperson' would believe to be an emergency. Assessment or treatment of the patient's emergency medical/psychiatric condition may not be delayed while ascertaining the person's ability to pay."

The hospital's Policy and Procedure titled, "Admission Process for Voluntary Patients," included: "The patient presents to the hospital's lobby and is greeted by the receptionist...The receptionist will give the patient paperwork...Upon completion of the paperwork, the patient returns the paperwork to the care center staff. Vital signs are completed and if stable, the patient will be assessed by the Clinician or RN...The clinician will assess the patient and determines level of care: 1. Inpatient 2. Intensive Outpatient 3. Partial Hospitalization Program 4. Makes a referral...."

The hospital's Policy and Procedure titled, "Assessment of Patients" included: "2. Intake/Care Center Assessment...On admission to the hospital, the Care Center Nurse documents initial assessment information on the Intake/Psychosocial Assessment form. This information will include: 1. Chief complaint with emphasis of why the patient has come for the appointment 'today'...2. Presenting problem...3. History of present illness...4. Mental Health Status...5. Determination of Level of Care indicated...Once the initial assessment is complete and the patient has all the information stated above: 1. The RN completes and reviews the assessment...2. Once the assessment has been thoroughly reviewed, the RN will contact the physician on-call and review the findings in the assessment...3. The physician will make a determination regarding the proper level of care for the person assessed...4. The RN will document his/her contact with the physician in a brief note that includes date/time of contact, the name of the physician contacted and the physician's recommendation for disposition; this will also be reflected on the Statement of Disposition for persons assessed but not admitted...."

Documentation in the Bylaw's of the Governing Authority and the Medical Staff Rules and Regulations included: "In addition to physicians, the following classes of practitioners are granted authority, within the scope of the clinical privileges or prerogatives for which they have been approved, to conduct medical screening examinations as required under the facility's EMTALA policy as a 'Qualified Medical Person': ...RN's with specified training."

Patient #1:

Documentation in the hospital's EMTALA Log 2019 dated 9/3/19, revealed Patient #1 walked in at 5:16 p.m. Documentation under the "Complaint" column on the log was "Psych." The patient's clinical record included a Triage Assessment form completed at 5:40 p.m. The top of the form included a section for vital signs including blood alcohol level (BAL). There were no vital signs recorded or any other pertinent information related to the patient's medical status. The RN's documentation included: "Pt states he is here for medication and housing." The RN did not document what "medication" the patient stated he needed. The RN's "Assessment Summary" included: " Pt. denies suicidal and homicidal thoughts. He states he is homeless and has nowhere to go...Currently not meeting criteria for admission." The RN documented Physician #1 was contacted who recommended the patient be discharged to himself.



Patient #3:

Patient #3 walked into the Care Center on 9/3/2019 at 7:14 p.m., with a complaint of "Detox." Documentation in the Triage Assessment form at 8:15 p.m. included: "Pt denies (danger to other/danger to self) dto/dts and (audio/visual) A/V hallucinations...Pt expresses she wants to detox and would like to go home to enroll her insurance...Dr. (name) recommends she discharge to self with family or friend...Pt denies dto/dts and A/V hallucinations. Pt requesting to go home so she is able to enroll in her insurance. Pt presents calm cooperative. Appears to be in no apparent distress. Pt discharged to a friend." There was no documentation of what substance(s) the patient was using, the amount, or the last time she used, and there were no basic vitals signs recorded. There was no documentation of why the topic of insurance was included during the assessment of the patient.

Patient #4:

Patient #4 walked into the Care Center on 9/19/2019 at 11:51 a.m., with a complaint of "Detox." The Triage Assessment was completed at 1:40 p.m., almost two hours after the patient arrived. Documentation in the Triage Assessment included: "Pt explains he wants a place to detox from Meth and have rehab...Dr. (name) recommends (discharge) d/c to self...denies suicidal and homicidal thoughts, denies A/V hallucinations. Appears to be in no apparent distress. Discharged to self with resources for further care. Basic vital signs were recorded on the form, however there was no other documentation of a medical or psychological screening performed other than asking the patient if they were any danger to self or others.



2. The first page of the admission packet provided to the patient was titled "Assessment Service Disclosure Statement and Consent to Assessment included: "Valley Hospital is not obligated to provide an assessment by a physician unless deemed necessary by the assessment clinician. Physician assessments are billable services. The following statement above the patient's signature line included: "I certify that I have read and fully understand the above consent for assessment. I agree to absolve Valley Hospital and its staff rendering the treatment(s) from any liability." The "Face Sheet" in the packet included the following statement at the top of the page: "All requested information must be completed for insurance claims to be correctly processed. Exclusion of insurance policy information may result in an insurance denial in which you will be totally responsible for your bill. Another page in the packet included: "I assign any and all insurance benefits payable to me to Valley Hospital. I understand that I am responsible for payment for services rendered at the Hospital...Should the account be referred to any attorney or collection agency for collection, I understand that I will be responsible for attorney or collection expenses. The form titled "Financial Information Verification" included: "I...SS#...authorize Valley Hospital to verify all financial information related to admission to the hospital, through the use of Equifax Healthcare Solutions."

Staff #5 reported during interviews on 9/25/2019, that every patient who walks into the Care Center is provided with an Admission Packet and a green "Care Center Vitals Sheet", initiated at the time they walk in. It was also reported that vital signs and "observation checks" were to be performed every 15 minutes until they were admitted or discharged. It was reported that if the patient was admitted, the information on the Care Center Vitals Sheets was transferred to inpatient admission assessment forms and the Care Center Vitals Sheet forms were destroyed. Staff #5 did not know why the Care Center Vitals Sheets were not retained in the clinical records of those patients who were not admitted.

Based on review of hospital policies and procedures, clinical record reviews, and staff interview, it was determined for three of three hospital to hospital transfers, the transfer form was not signed by the ordering physician according to their policies and procedures which poses a potential risk that the appropriate needs of the patient and treatment required will not be verified by the transferring physician if they fail to countersign the transfer. (Patients #8, #9, and #10)

Findings include:

The hospital's Policy and Procedure titled, "Hospital to Hospital Transfer" included: " PURPOSE: To ensure that Valley Hospital is in compliance witht he provisions of the EMTALA in the evaluation, treatment and/or transfer of all patients presenting for care. POLICY: It is the policy of Valley Hospital that...all transfers between hospitals will be medically appropriate and from physician to physician and from hospital to hospital...This policy applies to all individuals who present at Valley Hospital for emergency care and/or treatment...The physician's telephone order for transfer shall be written on the patient's medical record, signed by the hospital staff receiving the order, and countersigned by the physician authorizing the transfer as soon as possible...Prior to the transfer, the transferring physician shall secure a receiving physician and a receiving hospital that are appropriate to the medical needs of the patient and that will accept responsibility for the patient's medical treatment and hospital care."

Documentation in the hospital's Rules and Regulations of Medical Staff included: "The decision to transfer a person who has presented to a Facility with an 'emergency medical condition'...that has not been stabilized shall in all cases remain with a physician Member of the Medical Staff, and a written order will be obtained.

Patient #8:

Patient #8 was transferred from the hospital's Care Center to the emergency room of an acute care hospital on 8/31/2019, because the patient was having "difficulty breathing." The on-call physician directed the RN acting as the QMP at the Care Center to have the patient transferred. The QMP signed the hospital's transfer form, however, the ordering physician did not co-sign the transfer form.

Patient #9:

Patient #9 was transferred from the hospital's Care Center to the emergency room of an acute care hospital on 8/19/2019, for high blood pressure and blurry vision. The on-call physician who directed the QMP to transfer the patient did not sign the hospital's transfer form.

Patient #10:

Patient #10 was transferred from the hospital's Care Center to the emergency room of an acute care hospital on 8/23/2019, for chest pain. There was no documentation on the form that the patient was informed of the risks and benefits of transfer. The transfer form was signed by the QMP, however, it was not signed by the ordering physician.

Staff #5 stated during interviews that it was not the hospital's practice to have the on-call psychiatrist sign orders for patient transfers.

Based on review of facility documents, medical records from referring Emergency Departments, policies and procedures, and staff interviews, it was determined the hospital failed to fulfill it's obligation to accept five (4) patients, requiring admission for an emergency psychiatric condition, from a referring facility due to financial/insurance status. Failure to do so poses the potential risk of delaying specialized care and treatment to patients in need of psychiatric services and discriminates against patients due to their ability to pay for necessary services. (Patients #14, #15, #23, #24)

Findings include:

The "Intake Activity Log" is the log in which the Intake Coordinators document all the patient referrals received from outside entities in need of psychiatric admission.

The "Intake Activity Log" is an electronic documentation tool which is divided into four (4) sections for each referral received.
Section One: Caller/Patient Information
Section Two: Referral Information
Section Three: Legal, inclusive of Legal Status, Primary Payer, Patient's Employer
Section Four: Clinical and Disposition

Two (2) tables of disposition codes with their specific meaning were provided. The following codes with associated definitions revealed the following:

REFUS - PATIENT REFUSED ACTION - NO REFERRAL
RETRS - RETURNED TO REFERRAL SOURCE
REFIP - REFERRED TO INPATIENT NON-UHS (Universal Health Services) FACILITY
RAFNL - PATIENT REFUSED FINANCIAL OUT OF NETWORK CANNOT AFFORD PRIVATE PAY REHAB

Review of the "Intake Activity Log", from 08/17/2019 through 09/26/2019, revealed sixty four (64) patient referrals in need of psychiatric admission that were refused admission due to lack of health insurance or the inability of the facility to verify if these patients had health insurance benefits.

The "Intake Activity Log" and the Emergency Departments' (ED) medical records from referring facilities of five (5) randomly selected patients out of the sixty four (64) revealed:

Patient # 14

Patient presented to a community Emergency Department via police with suicidal ideation and depression on 08/17/2019.

ED physician documentation dated, 08/17/2019 at 1920 hours, revealed: "....Chief Complaint Suicidal ideation (due to) d/t relationship issues. Plan to stab...self and jump of (sic) cliff...Police were called because (Patient) PT was standing at top of ...(mountain) Mtn threatening to jump...."

The Behavioral Health Crisis Assessment completed on 08/18/2019 at 0132 hours revealed: "...Due to the lethal nature of the incident today, it was felt by all consulted as well as this writer that (higher level of care) HLOC was warranted and necessary for the (client's) Ct's safety and welfare...Client reluctantly accepted the disposition and is voluntary...."

Transfer Certification of Patient Request and Consent documentation dated, 08/18/2019 at 0321 revealed: "...Reason for Transfer- Availability of a higher level of care: Psychiatric Services...."

Disposition documentation of Patient #14's referral on the "Intake Activity Log", dated 08/18/2019 at 0237 hours, revealed: "...( Patient refused action No referral) REFUS...( Referred to Inpatient Non UHS ( Universal Health Services) Facility REFIP (Patient refused financial- Out of network cannot afford private pay rehab) RAFNL...." The section of the log where the primary payer/insurance is to be documented was blank.

Patient # 15

Patient presented to a community Emergency Department via (Emergency Medical Services) EMS with suicidal ideation on 08/24/2019.

ED physician documentation dated, 8/25/2019 at 0015 hours revealed: "...presents to the emergency department reporting suicidal ideation. Patient...drank a pint of whiskey...then cut...right arm with a straight razor...."

ED physician disposition documentation dated, 8/25/2019 at 0538 hours revealed: "...inpatient psych...."

The Behavioral Health Crisis Assessment completed on 08/25/2019 at 0921 hours revealed: "...(Care staff) CS assessed (client)Ct and based on reports, assessment, and staffing, CS...recommends HLOC for ct...Ct is voluntary for HLOC...."

Transfer Certification of Patient Request and Consent documentation dated, 08/25/2019 at 1345 revealed: "...Reason for Transfer- Availability of a higher level of care: Behavioral Health...."

Disposition documentation of Patient #15's referral on the "Intake Activity Log", dated 08/25/2019 at 1601 hours revealed: "...PATIENT SEEKING IP MH...REFUS...REFUS RAFNL...." The section of the log where the primary payer/insurance is to be documented was blank.

Patient # 23

Patient presented to a community Emergency Department with anxiety and suicidal ideation on 09/02/2019.

ED physician documentation, dated on 09/02/2019 at 1533 revealed: "...history of bipolar disorder, depression, and anxiety presenting to the emergency department with a chief complaint of suicidal ideations...Patient does not "want to be around anymore."...Patient has attempted suicide in the past via overdose...Seen by (Social Worker) SW and is agreeable to inpt psychiatric treatment. Medically cleared for this...."

Disposition documentation of Patient #23's referral on the "Intake Activity Log", dated 09/02/2019 at 1951 hours and again on 09/03/2019 at 0640 revealed: "...FINANCIAL...RETRS RAFNL...." The section of the log where the primary payer/insurance is to be documented was blank.

Patient # 24

Patient presented to a community Emergency Department with initial complaint of abdominal pain on 09/02/2019.

ED physician documentation, dated on 09/02/2019 at 0715 hours revealed: "...Patient initially presented with abdominal pain, nausea, vomiting, was medically cleared and prior to discharge expressed suicidal ideation...Social work has evaluated the patient, they believe that...suicidal ideation is genuine, patient is very tearful during conversation...medically cleared for discharge to psychiatric facility...."

Social Work documentation, dated on 09/02/2019 at 1016 hours revealed: "...Pt endorses desire to kill self...discussed inpatient psychiatric hospitalization process with patient...is agreeable to inpatient at this time...."

Social Work documentation, date on 09/02/2019 at 1213 hours revealed: "...Psychiatric services requested: Pt awaiting bed availability for inpatient psychiatric evaluation for SI and auditory and visual hallucinations...Referrals sent via NaviHealth to:...Valley Hospital...."

Disposition documentation of Patient #24's referral on the "Intake Activity Log", dated 09/03/2019 at 0308 hours revealed: :...UNABLE TO VERIFY BENEFITS...RETRS RAFNL...." The section of the log where the primary payer/insurance is to be documented was blank.

The policy and procedure titled, "EMTALA" revealed: "...PROCEDURE: Valley Hospital has a duty to follow the EMTALA regulations for hospitals with a Dedicated Emergency Room...."

The policy and procedure titled, "Hospital to Hospital Transfer" revealed: "...PURPOSE - To ensure that Valley Hospital is in compliance with the provisions of the EMTALA in the evaluation, treatment and/or transfer of all patients presenting for care. PROCEDURE: It is the policy of Valley Hospital that all individuals, regardless of race, religion, national origin, age, sex, physical condition, economic status or inability to pay to have equal access to emergency services and that all transfers between hospitals will be medically appropriate and from physician to physician and from hospital to hospital. With the exception of transfers based on mandated and designated providers, transfers of patients will also not be predicated upon arbitrary, capricious or unreasonable discrimination based on race, religion, national origin, age, sex, physical condition or economic status...."

The scope of services plan titled, "Valley Hospital Plan of Care" revealed: "...Screening and Intake - Valley Hospital accepts referrals from the professional community (physicians, courts, community agencies, education systems, psychologists and counselors), as well as by self or significant others. Intake screening and evaluations are performed by qualified Assessment counselors or by a member of the clinical supervisory staff, Social Services staff, registered nurse of active member of the Medical Staff, 24 hours per day, and seven days a week. The individual is advised of the program structure at the time of the evaluation and receives a recommendation for the appropriate level of treatment according to admission criteria and physician recommendation. Financial information is provided...."

The policy and procedure titled, "Assessment of Patients" revealed: "...1. Needs Assessment and Referral - Needs Assessment is the process of determining the treatment needs of a patient and coordinating a referral within Valley Hospital or alternate provider. An inquiry call form is completed by the Care Center and/or nursing personnel on each inquiry. The disposition of that individual is documented on the inquiry sheet...The information obtained on initial inquiries includes, but is not limited to: 1. Information about the caller's current condition/situation, including safety; 2. The type of services the caller is seeking; 3. Who referred the caller; and 4. Appropriate disposition...."

The policy and procedure titled, "Information and Referral Screening" revealed: "...Policy - It is the policy of Intake Services that during the receipt of an initial telephone call enough information is obtained to determine the appropriateness for an assessment at Valley Hospital...Procedure - 1. During the initial telephone contact the following demographic information should by obtained: A. Name B. Telephone Number C. Address D. Age E. Sex F. Referral Source...5. Obtain any other information which is pertinent to making a disposition. 6. Make a disposition based on the information received...."

Intake Services receive patient referrals via telephone, fax, web site, and Navi Health. No other policy was produced regarding facility's receipt of referrals or process once a referral is received.

Employee #5 reported, in an interview conducted on 09/18/2019, s/he was not certain why the Intake Coordinators would document on the "Intake Activity Log" that a referred patient was refused admission due to financial reasons. Employee #5 identified that it may be just a training issue with the Intake Coordinators.

Employee #6 reported, in an interview conducted on 9/19/2019 at 1045 hours, that the first piece of information that is looked at in the referral packet is whether the patient has insurance or not. If the patient does not have insurance or if not able to verify if the patient has insurance they do not accept the patient from the referring Emergency Department. Employee #6 identified that on 09/16/2019, s/he was told by Employee #11 that patients who do not have insurance are not to be accepted for admission if being referred from an Emergency Department.
Additionally, Employee #6 identified s/he had been instructed multiple times by Employee #5 not to accept referred patients from the Emergency Departments if the patients do not have insurance.

Employee#10 clarified, in an interview conducted on 09/19/2019 at 1215 hours, that when the code "REFUS" is documented on the "Intake Activity Log" it means the facility refused to accept the patient. It does not mean the patient refused the referral of admission to the facility.

Employee #11 confirmed, in an interview conducted on 09/19/2019 at 1500 hours, that the priority when reviewing patient referral packets is to identify those patients who have insurance first to fill the beds in the hospital over patients who do not have insurance.

Employee #10 confirmed, in an interview conducted on 09/25/2019 at 1300 hours, that it is the practice of the facility to refuse Emergency Department referrals for admission if the patients do not have insurance, or if it can not be verified if the patients have insurance. Additionally, Employee 10 identified that s/he received verbal instructions on 09/23/2019, from Employee #5 to still not accept referred patients from the Emergency Department if the patient does not have insurance. Employee #10 reported s/he was instructed to document on the "Intake Activity Log" "Refused", "Placed Elsewhere", or to utilize the code "RAFNL" for patients who do not have insurance who are referred from Emergency Departments, and not to document "Financial" or "Unable to Verify Benefits" in the comments section on the log.