HospitalInspections.org

Based on review of facility documents, on-call schedules, closed medical records (MR), and staff interviews (EMP), it was determined the facility failed to follow adopted policies related to on-call physician requirements to evaluate and care for all patients requiring the specialized capabilities of the facility in one of one medical records reviewed. (MR1)

Findings include:

Review of the Armstrong County Memorial Hospital's policy entitled "Behavioral Health Unit Admission", dated January 2010, stated "... Patients are accepted from a wide area, not exclusive to the catchment area of Armstrong-Indiana County ... ."

Review of the Armstrong County Memorial Hospital's policy entitled "Medical Coverage for Behavioral Health Services", dated January 2010, stated "There must be 24 hour-a-day coverage of the Behavioral Health Unit and behavioral health service to the hospital ... ."

1) Review of MR1 revealed the patient presented on December 26, 2009, to the transferring facility with depression. Further review of MR1 revealed nursing documentation dated December 27, 2009, timed 00:21, stating that ACMH Hospital was contacted for possible transfer. Nursing documentation stated "Call to ACMH to try to get pt [patient] to go there and they state they are not to call MD [Medical Doctor] after midnight and they said that they are not able to take pt [patient], states ... will talk to ... supervisor and call us back and we are to ask our MD [Medical Doctor] if MD [Medical Doctor] will keep pt here over night and ... will call their MD in am ... ."

2) Review of the on-call listing for psychiatry, dated August 24, 2009 to January 3, 2010, revealed that EMP20 was on call the evening of December 26, 2009.

3) Review of ACMH documents related to the events of December 26, 2009, revealed that EMP20 had relayed that staff were informed to contact [EMP20] at any time regarding patient admissions from Butler, Indiana, and Armstrong counties, but not other county referrals. EMP20 also stated that out of catchment area referrals would be reviewed in the morning.

4) Interview with EMP4 on January 13, 2010, at 1:40 PM, revealed "We were told to call if from Indiana, Armstrong, or Butler to call [EMP20]. If out of those areas, we were to wait until the morning and take the information, and for them to look for a bed in their own catchment area ... ."

5) An interview with EMP6 on January 14, 2010, at 8:30 AM, revealed "... It's an unwritten verbal law, about not calling [EMP20] through the night. I've heard them [Behavioral Health Unit staff ] talk about it ... ."

6) An interview with EMP20 on January 14, 2010, at 9:00 AM, revealed "... There is no policy, that they aren't to call ... The nurses are very considerate ... There's no rule they can't call ... It's the courtesy of the staff, of trying to wake [physicians] up as little as possible ... ."

7) An interview with EMP8, on January 14, 2010, at 1:45 PM, revealed "... We limit out of county calls, and only after midnight. This probably happened in the last four to five months. This was in the sense to call in the morning, not to not call at all. Nothing prompted this that I can recall. We wait until in the morning for those patients. I heard about this, by word of mouth."

8) An interview with EMP5 on January 14, 2010, at 1:50 PM, revealed "... staff told me that [EMP20] preferred not to be called between twelve [midnight] and six [6:00 AM]. I questioned [EMP20], and [EMP20] stated, yes, ... preferred not to be called for out of county referrals at night."

9) An interview with EMP 9, on January 14, 2010, at 2:00 PM, revealed "... I think we got an e-mail in the fall saying not to bother [EMP20] at night with out of catchment, and to wait until the morning, not don't call [EMP20] at all ... ."

10) An interview with EMP10 on January 14, 2010, at 2:20 PM, revealed "... That was an unofficial request to hold calls until morning, if possible. I don't know the exact directions. I just heard this was for through the night. There might have been an e-mail ... ."

11) A query was made by surveyors to EMP5 on January 14, 2010, inquiring as to whether an e-mail directive had been sent to staff related to limiting calls to physicians through the nights. EMP5 stated that an e-mail was not located.

Based on review of facility policies and procedures, closed medical records (MR), facility documents (OTH), and staff interviews (EMP), and interviews with others (OTH), it was determined the facility delayed further medical examination and treatment of patients, related to method of payment or insurance status in two of two medical records reviewed (MR1, MR42) and in two of 17 patient documents reviewed. (OTH4, OTH13)

Findings include:

Review of Armstrong County Memorial Hospital's policy entitled "EMTALA [Emergency Medical Treatment and Labor Act] (COBRA)", dated June 2008, stated "Policy: ... F. Accepting Transfers: ... 2. ACMH (including the ED and staff physicians) will not refuse to accept requests for transfers if the patient is in need of specialized capabilities or facilities available here unless ACMH lacks the capacity to safely treat the patient ... ."

Review of the policy entitled "Behavioral Health Unit Admission", stated "A person may be admitted to the behavioral health unit service at ACMH under the following conditions: 1. The patient suffers from a behavioral health disorder of such severity that he/she is unable to function at their normal capacity and/or presents a danger to self or others. 2. The patient suffers from behavioral health symptoms of such severity as to be intolerable to the patient and his/her significant others. 3. The patient is seeking evaluation, diagnosis, and referral for symptoms of mental illness. Individuals are admitted without regard to race, creed, color, religion, sex, or ability to pay. Patients are accepted from a wide area, not exclusive to the catchment area of Armstrong-Indiana County ... The psychiatrist-on-call will make decisions about accepting admissions and transfers ... ."

1) Review of MR1 revealed the patient presented to the transferring facility on December 26, 2009, and was accepted by ACMH Hospital for further treatment at 6:06 PM. Subsequent documentation at 9:33 PM revealed that the accepting physician at ACMH Hospital stated that the patient would not be accepted at this time, as they did not want to take the risk of the patient having to pay the bill in the event Medicare does not pay.

Interview with EMP4, on January 13, 2010, 1:40 PM, revealed "The patient had Medicare, [EMP20] was concerned [the patient] would get stuck with the bill. There was a mix - up with the insurance. Indiana had called with the referral ... I took the information, and called the doctor. I waited for them to call back with the precert. I called them back, and was put on hold, because she was on the line with Blue Cross, and they said we weren't in the network, and Blue Cross recommended facilities. Then the RN (registered nurse )called back and said the patient had straight Medicare. I think the concern was that we had a lot of different stories. You don't need a precert for straight Medicare. I called the physician. [EMP20] was concerned either she or we would be stuck with the bill, and wait until morning ... Insurance is not usually an issue. I think [EMP20] was concerned [the patient] or us would be stuck with the bill."

Interview with EMP20, on January 14, 2010, at 9:00 AM, revealed "I remember initially getting a call. The patient had an odd out of state insurance, and was recently treated at another facility. If we're not in the network, I wanted to spare [the patient] the out of network co-pay. I think I got another call about Medicare, and then another call in the morning, they said they couldn't find her a bed, so I said we'll take [the patient] ... We try to accommodate the insurance network. We have taken them if we need to and try to minimize the out of network copay or we'll refer them to someone. We always treat, regardless of ability to pay. We do the right things for patients. We'll eat the cost if we have to ... The first call [about the patient in question], it was out of state insurance. I was told they had been seen recently at another facility, and suggested they go there for continuity of care. That continuity is very invaluable. It was my understanding [the patient] had been recently treated at another facility. The stays are so short, so continuity is very important. Sometimes it can take a while to get outpatient records. Continuity is a priority. It's difficult when patients are counties away. We assess everyone on an individual basis. In the morning, we know who is going to be discharged, so we'll reassess. I assumed that admission would be based on the most recent admission. The pay was not the issue. It was continuity for her. If I had been told there were no beds for [the patient], if [the patient] had been a resident of one of these counties, we take them all. Continuity is the first thing. In the morning, I was told no one would take [the patient. If they called me at 2:00 AM, and told me they no beds, I would have taken [the patient] ... Administration told us to take care of the patients, and they'll worry about the insurance. They do the right thing ... ."

2) Review of OTH4, dated July 21, 2009, revealed documentation on the form indicating the facility was contacted by another facility for possible placement of a patient. Documentation on the form stated that the psychiatrist who had been called refused admission of the patient. Documentation states that the reason for refusal as "out of county. [no] insurance."

Review of OTH13, dated November 24, 2009, revealed documentation on the form indicating the facility was contacted by another facility for possible placement of a patient. Documentation on the form stated that the psychiatrist who had been called refused admission of the patient. Documentation states that the reason for refusal as "No Ins [insurance]/out of county."

Interview with EMP5, on January 14, 2010, at approximately 3:30 PM, confirmed the findings on the forms.

3) Review of MR42 revealed the patient presented to the transferring facility on January 18, 2010, and was accepted by ACMH Hospital for further treatment at 2:45 AM. Subsequent documentation at 3:38 AM revealed that patient was aware treatment at ACMH Hospital would be self pay. Continued review of documentation, timed 3:56 AM revealed that the transferring facility was contacted by EMP17 at ACMH Hospital, stating that an authorization number is needed before the patient's transfer can take place. Documentation also stated that EMP17 requested to have patient remain at the transferring facility until the insurance company opened at 8:00 AM in order to obtain a precertification.

Interview with EMP17 on January 18, 2010, at 3:30 PM, revealed "I got a call from 2 A [Behavioral Health] stating that Indiana [IRMC] had called and we were going to get a patient. Shortly after two, I got a call from Indiana and that the patient was going to be a self pay. We got into a long conversation ... We were discussing that this was very sad, and that it was awful the poor [patient] was depressed and suicidal and going to get slapped with a transportation and inpatient bill ..."[IRMC staff] told me the patient ... the patient would be a self pay, because they don't have psych benefits ... I called and asked [the nurse in Indiana] what we could do for this [patient], I'm afraid [the patient] is going to get socked with all of these bills. I said it was too bad [the patient] didn't come in later ... After that, the nurse [from Indiana] got back on the phone and said they could keep the patient until morning. I said "Can you do that?", and "that's great." I told them to call me or the admissions office with the authorization number. We got off the phone ... Part of the conversation with the nurse in Indiana, was that I told them I didn't care how [the patient] pays, I'd rather have [the patient] have a bill then go and kill [themselves] ... ."

Interview with EMP18, on January 26, 2010, at approximately 9:15 AM, revealed "We got a call at 2:45 from IRMC [Indiana Regional Medical Center] about a possible admission. They said [the patient] was a 201 [voluntary commitment], with suicidal ideations. I called and got it okayed from [EMP20]. An hour later, they called me back and said they spoke with [the patient's insurance] and they don't cover inpatient and the patient would have to be a self pay. I called [EMP20] back and said okay. I called them [IRMC] back and they told me [the patient] would be self pay ... EMP17 said [they] called Indiana to see if they could hold the patient until 8:00 AM, because [they] didn't want the patient who was depressed to get a high bill. The patient was thinking about going home. I was going to call my unit manager and the supervisor and before I called them, I got a call from IRMC and they said the patient went home. I know [EMP17] said to me that she didn't tell them not to send the patient, just to try to hold the patient to try to get precert."

Interview with OTH19 on January 26, 2010, at 11:15 AM, revealed " We made arrangements for the patient to be transferred. The patient was aware of the self pay responsibility. Armstrong Hospital called they felt it was better for the patient to stay here until the insurance could be contacted at 8AM. The caller had the patient best interest to have the authorization, for the chance the insurance would not pay. The caller did not want [the patient] to get billed for an admission. They never refused to take the patient. The patient was initially agreeable and the physician agreed to keep [the patient] here. We contacted the ambulance to cancel the transfer. After awhile the patient wanted to go home. Armstrong hospital never refused to take the patient. "

Based on review of facility policies and procedures, closed medical records (MR), facility documents (OTH), and staff interviews (EMP), it was determined the facility failed to follow adopted policies related to the accepting of transfers of patients from a referring facility for seven of the 17 patient documents reviewed. (OTH1, OTH4, OTH6, OTH9, OTH12, OTH12, OTH13, OTH14)

Findings include:

Review of Armstrong County Memorial Hospital's policy entitled "EMTALA [Emergency Medical Treatment and Labor Act] (COBRA)", dated June 2008, stated "Policy: ... F. Accepting Transfers: ... 2. ACMH (including the ED and staff physicians) will not refuse to accept requests for transfers if the patient is in need of specialized capabilities or facilities available here unless ACMH lacks the capacity to safely treat the patient ... ."

Review of the policy entitled "Behavioral Health Unit Admission", stated "A person may be admitted to the behavioral health unit service at ACMH under the following conditions: 1. The patient suffers from a behavioral health disorder of such severity that he/she is unable to function at their normal capacity and/or presents a danger to self or others. 2. The patient suffers from behavioral health symptoms of such severity as to be intolerable to the patient and his/her significant others. 3. The patient is seeking evaluation, diagnosis, and referral for symptoms of mental illness. Individuals are admitted without regard to race, creed, color, religion, sex, or ability to pay. Patients are accepted from a wide area, not exclusive to the catchment area of Armstrong-Indiana County ... The psychiatrist-on-call will make decisions about accepting admissions and transfers ... ."

1) An interview with EMP5 on January 13, 2010, at 1:50 PM, revealed "... [Related to catchment areas] "We try to get the patients back to their own area for follow up and transportation, back to their own county. We always accommodate the three, Indiana, Armstrong are in our catchment, but we make an exception for Butler, because [EMP20] goes there."

2) An interview with EMP20, on January 14, 2010, at 9:00 AM, revealed "... "The ER calls 2A, and fill out the log form. They would then contact me or the physician on call. During the day, the ER's would call me until 5:00 PM. Then the doctor on call would be contacted ... [ Related to out of county patients], "We've had admissions, and can't get petitioners to come. The review officers are strict about the letter of the law. We don't have any grounds while they were here, and the person was discharged because the petitioner didn't come in. If we don't have grounds, we have to discharge." EMP20 further stated "Out of county is determined by always having a bed available for Indiana, Armstrong, and Butler residents, for our county. Our group covers Indiana, Armstrong, and Butler counties. We make sure beds are available for residents of these counties ... ."

3) A review of the Behavioral Health Unit's Admission Book was completed. The book contained forms entitled "Behavioral Health Admission Log." A review of a sample of 17 forms revealed that seven of the 17 forms documented that the reason the patient was refused was because they were out of county. (OTH1, OTH4, OTH6, OTH9, OTH12, OTH13, OTH14)

Review of OTH1, dated July 15, 2009, revealed documentation on the form indicating the facility was contacted by another facility for possible placement of a patient. Documentation on the form stated that the psychiatrist who had been called refused admission of the patient. Documentation states that the reason for refusal as "out of county 302."

Review of OTH4, dated July 21, 2009, revealed documentation on the form indicating the facility was contacted by another facility for possible placement of a patient. Documentation on the form stated that the psychiatrist who had been called refused admission of the patient. Documentation states that the reason for refusal as "out of county. [no] insurance."

Review of OTH6, dated September 26, 2009 revealed documentation on the form indicating the facility was contacted by another facility for possible placement of a patient. Documentation on the form stated that the psychiatrist who had been called refused admission of the patient. Documentation states that the reason for refusal as "out of co [county] 302."

Review of OTH9, dated November 6, 2009, revealed documentation on the form indicating the facility was contacted by another facility for possible placement of a patient. Documentation on the form stated that the psychiatrist who had been called refused admission of the patient. Documentation states that the reason for refusal as "out of county."

Review of OTH12, dated November 23, 2009, revealed documentation on the form indicating the facility was contacted by another facility for possible placement of a patient. Documentation on the form stated that the psychiatrist who had been called refused admission of the patient. Documentation states that the reason for refusal as "out of county."

Review of OTH13, dated November 24, 2009, revealed documentation on the form indicating the facility was contacted by another facility for possible placement of a patient. Documentation on the form stated that the psychiatrist who had been called refused admission of the patient. Documentation states that the reason for refusal as "No Ins [insurance]/out of county."

Review of OTH14, dated December 29, 2009, revealed documentation on the form indicating the facility was contacted by another facility for possible placement of a patient. Documentation on the form stated that the psychiatrist who had been called refused admission of the patient. Documentation states that the reason for refusal as "out of area."

4) Interview with EMP5, on January 14, 2010, at approximately 3:30 PM, confirmed the above findings on the forms. EMP5 further confirmed that on the above dates the Behavorial Health Unit had available beds, and that staffing was consistent with the facility's staffing guidelines.