HospitalInspections.org

Based on document review and interview, the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure patients were appropriately transferred. See deficiency A-2409.

Based on document review and interview, it was determined that for 2 of 2 psychiatrists (MD #1 and MD #2), the Hospital failed to ensure behavioral health patients were not inappropriately transferred to another hospital with the same level capabilities, due to non-funding. This has the potential to affect all behavioral health patients serviced by the Hospital.

Findings include:

1. The Hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)" (revised 08/2017) was reviewed on 12/27/17 and required, "To provide nondiscriminatory care by complying with the federal Emergency Medical Treatment and Active Labor Act (EMTALA)...Psychiatric Emergency Medical Condition: an individual with a psychiatric condition shall not be treated differently than any other individual who presents to the Emergency Department with an emergency medical condition. That is, if an individual is determined by a qualified medical practitioner to be dangerous to him/herself or others by reason of mental illness, that individual would be considered to have an emergency medical condition..."

2. The Emergency Patient Transfer Out Logs were reviewed from 1/1/17 through 12/27/17. There were 3 non-funded behavioral health patients (Pt #21, Pt #22 and Pt #24) identified as being held in the ED for a prolonged period of time awaiting transfer to the State Hospital. These 3 clinical records were reviewed and included the following:

-Pt #21 was a 46 year old male who presented to the Hospital's ED on 2/20/17 at 1:42 PM with a complaint of suicidal ideation. The Behavioral Health Intake Progress Note, dated and timed 2/20/17 at 6:38 PM, included" ...Pt will be referred to [State Hospital] ..." The nurse's notes indicated that Pt #21 was transferred to the State Hospital on 2/21/17 at 6:15 PM.

-Pt #22 was a 31 year old male who presented to the Hospital's ED on 4/24/17 at 9:58 PM with a complaint of aggression. Pt #22's registration form included that Pt #22 was "self pay". The Behavioral Health Intake Progress Note, dated and timed 4/25/17 at 4:04 AM, included, " ...Pt is unfunded and will refer to [State Hospital] ..." The nurse's note dated 4/25/17 at 5:00 PM included, "The patient has been accepted at [State Hospital] request patient to arrive at 8:00 PM." Pt #22 was transferred to the State Hospital at 7:45 PM on 4/25/17.

-Pt #24 was a 36 year old female who presented to the Hospital's ED on 1/14/17 at 2:25 AM with a complaint of suicidal attempt. The Behavioral Health Intake Coordinator's note at 2:25 AM included, " ...Pt is unfunded and will be referred to [State Hospital]. @2:22 AM 1/14/17 intake specialist contacted [State Hospital] regarding this patient pending admission ...stated that the patient was accepted ...but awaiting an available bed ..." The ED nurse's note, dated and timed 1/15/17 at 9:17 AM, included, " ...ambulance here to pick up pt."

3. The census and staffing on the Behavioral Health Units were reviewed on 12/28/17 at approximately 9:15 AM for 1/14/17, 2/20/17, and 4/24/17. There were available beds and adequate staffing on the inpatient units while Pt #21, Pt #22, and Pt #24 were being held in the ED awaiting transfer to the State Hospital.

4. The Behavioral Health inpatient admissions were reviewed for MD #1 and MD #2 from 10/1/17 through 12/27/17. MD #1 had no non-funded patient admissions, and MD #2 had only 3 non-funded patient admissions for this time period.

5. On 12/27/17 at approximately 12:30 PM, an interview was conducted with the Director of Behavioral Health (MD #1). MD #1 stated that if a patient meets the criteria for inpatient admission, then the patient is admitted. MD #1 stated that every patient is seen in the ED prior to admission. Patients are admitted based on the Intake Coordinators assessment and the ED physician's assessment. If the patient meets the criteria for inpatient admission, and the patient is non-funded, the patient is referred to the State Behavioral Health Hospital. If it takes longer than 36 hours to transfer the patient to the State Hospital, then the patient is admitted to the Hospital's inpatient behavioral health unit. If it is less than 36 hours, then the patient remains in the ED until transferred. MD #1 stated that the patients are not seen in the ED by a psychiatrist while being held for transfer. MD #1 stated that no patient is ever refused admission to the Hospital due to lack of funding.

6. On 12/27/17 at approximately 1:00 PM, an interview was conducted with the Hospital's Chief Medical Officer (MD #6). MD #6 stated that the expectation of the Hospital is that all patients receive an evaluation and treatment. If a behavioral health patient is non-funded, it may make sense to go to the State Behavioral Health Hospital. However, that patient should not wait more than 4 hours to be transferred to an inpatient unit. The process is supposed to be that a funded patient is seen by the intake team, discussed with the psychiatrist, and admitted to the inpatient unit at the Hospital. A non-funded patient is seen by the intake team, discussed with the psychiatrist, and if no bed at the State hospital is available within 4 hours, the patient is placed in an inpatient bed on the behavioral health unit at the Hospital while they continue to look for a bed to transfer the patient to the State hospital when available.

MD #6 stated that there are significant challenges related to this process at the Hospital. The 2 psychiatrists (MD #1 and MD #2) contracted with the Hospital are adamantly opposed to admitting non-funded patients to the Hospital. MD #6 stated that meetings were held in September 2017 and October 2017 with MD #1 and MD #2 to discuss the expectations. The Hospital even offered to pay the psychiatrists for the non-funded patients' admissions. However, MD #1 and MD #2 continue to not accept non-funded patients which causes extensively long wait times for patients, sometimes greater than 24 hours, waiting for a bed at the State hospital. MD #6 stated that there have been no improvements since these meetings with MD #1 and MD #2. The Hospital is actively recruiting psychiatrists, but currently only have MD #1 and MD #2 providing psychiatric treatment at the Hospital. Therefore, the Hospital has not pursued anything adverse against MD #1 and MD #2. MD #1 and MD #2 were told that the admission of non-funded patients was part of their contractual obligation and could affect their licenses.

7. On 12/28/17 at approximately 12:15 PM, an interview was conducted with MD #2 (psychiatrist). MD #2 stated, "I am an independent practitioner and decide if patients meet criteria for admission based on information I am provided by the intake coordinator. Unfunded patients automatically go to [State Hospital]. I do not take unfunded patients. Should I?"

8. On 12/28/17 at approximately 10:11 AM, a group interview was conducted with the Management Executive Team which included: Chief Operating Officer (E #8), Chief Executive Officer (E #9), and the Hospital's Attorney (E #10). E #9 stated that the Hospital was aware that there was an ongoing challenge due to the shortage of psychiatrists. E #9 stated that there were concerns with MD #1 and MD #2 not admitting non-funded patients. E #9 stated that they have had several conversations with MD #1 and MD #2 regarding their violation of their contracts with the Hospital due to their ongoing refusal to come in when needed and refusal to admit non-funded patients to the Hospital.

The Chief Operating Officer (E #8) stated that there had been several conversations with MD #1 and MD #2 regarding their contracts with the Hospital and told that it was clearly the expectation of the Hospital for them to care for all patients regardless of funding and compliance with EMTALA. E #9 stated that the Hospital was addressing each incident case by case. E #9 stated that when the Hospital becomes aware of patients being held in the ED for transfer for an extended period of time, the Hospital intervenes. However, E #9 stated that there was no system in place for the notification of Hospital administration regarding behavioral health patients being held awaiting transfer other than asking the ED physicians to let them know.