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During an EMTALA investigation of complaint #49630 completed on 11/6/19 - 11/8/19, Starr Regional Medical Center Athens was found to be out of compliance with Requirements for the Responsibilities of Medicare Participating Hospitals in Emergency Cases 42 CFR PART 489.20 (l)(r)(3) and 489.24.

The findings include:

Based on review of facility policies, review of Medical Staff Bylaws, review of agreements with contracted providers, review of medical records, review of Physician's on-call schedules, review of hospital census reports, and interviews, the facility failed to:

1. Ensure the on-call Tele-Medicine/Psychiatry Physician was utilized by the Emergency Department (ED) to provide further evaluation and treatment for 4 patients (#3, #22, #27, and #30) of 14 psychiatric patients reviewed of 37 ED records reviewed.

2. Admit patients to the facility's inpatient geriatric psychiatric unit when the unit had capability and capacity to provide care for 4 ED patients (#12, #22, #27, and #30) of 14 psychiatric patients reviewed of 37 ED records reviewed.

Refer to A-2404, and A-2409.

Based on review of facility policies, review of Medical Staff Bylaws, review of agreements for contracted Tele-Psychiatric Services, review of physician's on-call schedules, medical record reviews, and interviews, the facility failed to ensure on call tele-psychiatrists, who were available and on-call for duty provided evaluation and/or treatment for 4 Emergency Department (ED) patients (#3, #22, #27, and #30) with psychiatric conditions reviewed of 14 psychiatric patients reviewed of 37 ED records reviewed.

The findings included:

Review of facility policy, "Emergency Screening Stabilization/Transfer/250 Yard Rule and EMTALA [Emergency Medical Treatment and Labor Act]" dated 3/2019, revealed "...If an emergency medical condition is found to exist, the hospital will (without regard for the patient's insurance or ability to pay) provide) stabilizing treatment within the capabilities of the hospital and its staff...On-Call list refers to the list that the Hospital is required to maintain which defines those physicians who are on-call, directly or by arrangement, to assist the emergency department physician or QMP [Qualified Medical Personnel] in the care of the patient after the initial Medical Screening Examination, to provide further evaluation and/or treatment necessary to stabilize an individual with an Emergency Medical Condition...If a Hospital offers a service to the public, the services should be available to patients of the emergency department..."

Review of the facility's "BYLAWS OF THE MEDICAL-DENTAL STAFF" dated 10/2019, revealed "...A call list for primary care and specialty consultants is prepared monthly and posted in the Emergency Center of each campus, for those services provided at each campus...It is the responsibility of the contract service to provide adequate physician coverage for the Emergency Center..."

Review of a Master Services Agreement for Tele-Psychiatric Services dated 7/17/18 revealed "...will provide tele-psychiatrist to work virtually at the facilities requested...in coordination with Client, Assigned Tele-Psychiatrist who shall provide tele-psychiatry services...Evaluate, diagnose and treat patient in the Emergency Department...be available 24 hours per day 7 days per week by telephone to provide consultation/second opinion regarding any assessed patient who is declined admission by the on-call psychiatry staff..."

Review of the Physician's On-Call Schedules from 5/2019 to 11/2019, revealed the facility did not have a psychiatrist on-call.

1. Medical record review revealed Patient #3, a 76 year old female, presented to Hospital A's ED by Emergency Medical Service (EMS) on 8/30/19 at 5:52 PM for complaint of taking 60 Lorazepam (anti-anxiety medication) 1 milligram (mg) pills. Continued review revealed the patient was provided a Medical Screening Examination (MSE) by an Osteopathic Physician (DO) on 8/30/19 beginning at 6:02 PM.

Medical record review of a Physician's note dated 8/31/19 at 1:00 AM revealed "...CON [Certificate of Need/involuntary admission/committal form] completed..."

Medical record review of the CON form dated 8/31/19 at 1:00 AM revealed "...Patient attempted to commit suicide by overdose. Patient is danger to herself. Failure to place the patient under involuntary commitment could result in serious harm to the patient...Patient is a danger to herself..."

Medical record review of a Mobile Crisis Consult form dated 8/31/19 at 4:15 AM revealed "...overdosed on meds [medications] earlier in a clear suicide attempt. Reports to med [medical] staff that she does not want to live...CON signed...Final Disposition...Involuntary Inpatient..."

Medical record review of a Nurse's note dated 9/2/19 at 8:43 AM revealed "...called [Hospital C] to ask about bed placement...they state they are declining pt [patient]...called [Patient #3's] daughter...and adv [advised] we are unable to place pt in a facility and she [daughter] needs to come and get mom [Patient #3]...she states she is unable to take care of her at her home and doesn't want to get her...adv her this is ER [emergency room] and not a long term care facility and she needs to come get her mom and try nursing home placement or take care of her at home, we have exhausted all of our places to take her...adv her I am sorry but this happens to a lot of pts [patients]..."

Medical record review of a Physician's note dated 9/2/19 at 1:00 PM revealed "...Every attempt has been made to place this patient. She will be discharged home with her daughter..."

Medical record review of a Nurse's note dated 9/2/19 at 1:16 PM revealed the Patient #3 was discharged home with family (3 days after arrival to the ED).

Medical record review revealed no documentation the tele-psychiatrist on-call was consulted regarding assessment or treatment of Patient #3's psychiatric condition.

Medical record review revealed Patient #3 presented to Hospital B's ED on 11/1/19 at 2:35 PM (approximately 2 months after presenting to Hospital A), via the police department, for a complaint of "wanting to die." Continued review revealed the patient was provided a MSE by a physician on 11/1/19 at 2:39 PM.

Medical record review of a Physician's note dated 11/1/19 at 2:53 PM revealed "...she repeatedly denies that she has any intention of harming herself...She does admit to severe depression...[Patient #3 stated] 'If I dropped dead I would not care but I would never harm myself'...She is oriented to person place time and knows the current president. She is agreeable to signing herself in for treatment..."

Medical record review of a Physician's note dated 11/1/19 at 4:24 PM revealed "...The pt does not meet criteria for a CON...I called CRISIS [Crisis Response Team] and discussed the situation with them and they are in agreement that if the patient is not homicidal or suicidal, or otherwise in a dangerous mental state she does not meet criteria for CON..."

Medical record review revealed Patient #3 was discharged home with family on 11/1/19 at 6:32 PM.

Medical record review revealed no documentation the tele-psychiatrist on-call was consulted regarding assessment or treatment of Patient #3's psychiatric condition.

2. Medical record review revealed Patient #22 presented to Hospital A's ED on 6/10/19 at 6:26 AM for complaints of anxiety. Continued review revealed the patient had a MSE initiated by a Physician on 6/10/19 at 6:35 AM.

Medical record review of a Physician's note dated 6/10/19 at 6:46 AM revealed "...The patient presents to the emergency department with paranoia, suicide ideation, and the patient has a plan, to shoot self...spoke with Mobile Crisis and they told her to come to the ED and get placed..."

Medical record review of a Nurse's note dated 6/10/19 at 1:00 PM revealed "...Psych [psychiatric] services to see [Patient #22]. Crisis Response Team [CRT]..."

Medical record review of a CON form dated 6/10/19 at 2:45 PM revealed "...Poses risk of self harm...Needs secure setting with 15 minute checks, pharmaceutical stabilization and therapy..."

Medical record review of a Physician's note dated 6/11/19 at 7:11 PM revealed "...The patient is being admitted for inpatient psychiatric evaluation and treatment..."

Medical record review of a CRT Consult record dated 6/11/19 (no time documented) revealed "...[Patient #22] is endorsing SI [suicidal ideation] and earlier today voiced desire to shoot herself. Indicates anxiety and panic feelings...can't be safe and feels she is at risk for self harm...has been referred to [Hospital D]..."

Medical record review of a Nurse's note dated 6/12/19 at 9:10 AM revealed "...Received call from [named person] with CRT. States pt has been accepted to [Hospital D]..."

Medical record review revealed Patient #22 was transferred to Hospital D on 6/12/19 at 9:58 AM.

Medical record review revealed no documentation the tele-psychiatrist on-call was consulted regarding assessment or treatment of Patient #22's psychiatric condition.

3. Medical record review revealed Patient #27, a 75 year old female, presented to Hospital A's ED on 5/2/19 at 6:04 PM for complaint of altered mental status. Continued review revealed the patient had a MSE initiated by a Physician on 5/2/19 at 6:24 PM.

Medical record review of a CON dated 5/2/19 at 6:27 PM revealed "...Patient has severe depression with suicidal thoughts. She states she wishes to end her life by cutting herself and letting herself bleed out...requires treatment for depression...poses a risk to herself if sent home..."

Medical record review of a Physician's order dated 5/2/19 at 7:23 PM revealed "...Consult Orders - Crisis Response Services..."

Medical record review of a Nurse's note dated 5/2/19 at 7:44 PM revealed "...crisis [CRT] notified of eval [evaluation]..."

Medical record review revealed Patient #27 was transferred to Hospital E on 5/3/19 at 8:54 AM.

Medical record review revealed no documentation the tele-psychiatrist on-call was consulted regarding assessment or treatment of Patient #27's psychiatric condition. Further review revealed no documentation the consult was completed by CRT.

4. Medical record review revealed Patient #30, a 70 year old female, presented to Hospital A's ED on 5/30/19 at 10:24 PM for complaint of taking an unknown number of Hydrocodone (pain medication), Ambien (sleeping pill), and other unknown medications. Continued review revealed a MSE was completed by the Physician on 5/30/19 at 10:32 PM.

Medical record review of a CON form completed by the facility dated 5/30/19 at 10:32 PM revealed "...Patient brought to Emergency Department after intentional overdose of chronic medications including controlled substances. Patient has history of depression and remains confused at this time. Patient is, at this time, a danger to herself and others...Patient unable to maintain personal safety at this time and remains a danger to herself...Patient requires immediate inpatient treatment..."

Medical record review of a Physician's note dated 5/31/19 at 12:27 AM revealed "...need to transfer to another facility [Hospital A] does not immediately have the required specialist..."

Medical record review of a Physician's note dated 5/31/19 at 1:58 AM revealed "...Other consultation...Case reviewed with...CRT by phone...Referrals made for psychiatric evaluation/treatment..."

Medical record review of a Nurse's note dated 5/31/19 at 2:44 PM revealed "...[Hospital E] called to decline pt at this time, MD [at Hospital E] states too soon after ingestion of medication..."

Medical record review of a Physician's note dated 5/31/19 at 6:34 AM revealed "...[Patient #30] Transfer ordered to Other Psych Hospital [Hospital C]. Diagnoses are Major depressive disorders...poisoning by other antiepileptic and sedative-hypnotic drugs, intentional self-harm..."

Medical record review revealed Patient #30 was transferred to Hospital C on 5/31/19 at 12:22 PM.

Medical record review revealed no documentation the tele-psychiatrist on-call was consulted regarding assessment or treatment of Patient #30's psychiatric condition.

Telephone interview with Psychiatrist #1 on 11/7/19 at 8:50 PM revealed he was the Psychiatrist for Hospital A's geriatric psychiatric unit. Continued interview revealed he was only on-call for patients admitted to the geriatric psychiatric unit and he was never on-call for ED patients and has never assessed or treated psychiatric patients in the ED at Hospital A or Hospital B.

Interview with the Risk Manager and the ED Director on 11/8/19 at 10:00 AM, in the Administrative Conference Room, revealed the facility does not have a psychiatrist on call for the ED at Hospital A or Hospital B. Continued interview revealed the facility has a contracted Tele-Psychiatric Service that provided a tele-psychiatrist on call 24 hours per day 7 days per week to Hospital A and Hospital B and can provide psychiatric assessments via computer interviews with the ED patients. Further interview revealed the decision to consult the tele-psychiatrist was made by the treating ED Physician and the tele-psychiatrists consult with the ED physicians in order to make diagnosis and treatment recommendations. Continued interview revealed CRT often visits the patients in the ED for face to face assessments, but CRT does not provide treatment or make treatment recommendations to the ED physicians. Continued interview revealed CRT provided case management, assistance with referrals, and assistance in finding placement in outside facilities. Further interview confirmed the tele-psychiatrist was not consulted regarding psychiatric related conditions for Patient #3, Patient #22, Patient #27, and Patient #30.

Based on review of facility policies, medical record reviews, review of census records, and interviews, the facility inappropriately transferred 4 Emergency Department (ED) patients (#12, #22, #27, and #30) with a psychiatric condition when the facility had the capability and capacity to provide inpatient psychiatric treatment of 14 psychiatric patients reviewed awaiting inpatient psychiatric admission of 37 ED records reviewed.

The findings included:

Review of facility policy, "Emergency Screening Stabilization/Transfer/250 Yard Rule and EMTALA [Emergency Medical Treatment and Labor Act]" dated 3/2019, revealed "...If an emergency medical condition is found to exist, the hospital will (without regard for the patient's insurance or ability to pay) provide) stabilizing treatment within the capabilities of the hospital and its staff..."

Review of facility policy titled "Admission Criteria" dated 8/2015, revealed "...The Hospital's process for admission to the psychiatric unit is based on each patient's assessed needs...Admission to the Psychiatric Program is indicated for patients above the age of 50 who have a DSM-5 [Diagnostic and Statistical Manual of Mental Disorders] diagnosis...Admission criteria is applied uniformly to both Medicare and Non-Medicare patients...Suicide attempts, threat to self...Homicidal Ideation...Assaultive behavior threatening others...Psychiatric symptoms...Cognitive impairment..." Continued review revealed no exclusion criteria for patients with committals/involuntary admissions. Further review revealed no requirement for patients to be voluntary admissions.

1. Medical record review revealed Patient #12, a 78 year old female, presented to Hospital A's ED on 8/30/19 at 11:05 AM for complaint of psychiatric problems. Continued review revealed the patient had a Medical Screening Examination (MSE) initiated by a physician on 8/30/19 at 11:28 AM.

Medical record review of a Physician's note dated 8/30/19 at 11:44 AM revealed "...presents to the emergency department with paranoia, delusions..."

Medical record review of a Nurse's note dated 8/30/19 at 1:00 PM revealed "...Tele-Medicine Exam...Set up tele medicine computer in room at patient's bedside for Tele Psych Consult...Assist physician with his tele psych exam..."

Medical record review of a Certificate of Need (CON) (involuntary admission/committal form) dated 8/30/19 at 1:22 PM revealed "...Patient has long history of paranoia and delusions, discussed with psychiatrist and she [Patient #12] needs involuntary placement and treatment...patient is appearing acute psychotic break with worsening paranoia and delusions and is a danger to herself..."

Medical record review of a Physician's note dated 8/30/19 at 1:27 PM revealed "...[Tele-Medicine Psychiatrist] has agreed patient needs involuntary commitment at an inpatient psych facility at this time. A CON has been filled out and we will await placement..."

Medical record review of a Nurse's note dated 8/30/19 at 11:04 PM revealed "...Spoke with [Hospital E] concerning patient placement...they will call back with potential placement after speaking with the physician..."

Medical record review of a Nurse's note dated 8/31/19 at 12:10 AM revealed "...pt accepted to [Hospital E]...cannot be taken until after 0700 [7:00 AM]..." Continued review revealed the patient was transferred from Hospital A to Hospital E on 8/31/19 at 1:33 PM (26.5 hours after arrival to the ED).

Review of the census records for the geriatric psychiatric unit at Hospital B (satellite campus of Hospital A) revealed on 8/30/19 and 8/31/19 the facility had vacant beds available for female patients on the unit.

2. Medical record review revealed Patient #22 presented to Hospital A's ED on 6/10/19 at 6:26 AM for complaints of anxiety. Continued review revealed the patient had a MSE initiated by a Physician on 6/10/19 at 6:35 AM.

Medical record review of a Physician's note dated 6/10/19 at 6:46 AM revealed "...The patient presents to the emergency department with paranoia, suicide ideation, and the patient has a plan, to shoot self...spoke with Mobile Crisis and they told her to come to the ED and get placed..."

Medical record review of a Nurse's note dated 6/10/19 at 1:00 PM revealed "...Psych [psychiatric] services to see [Patient #22]. Crisis Response Team [CRT]..."

Medical record review of a CON form dated 6/10/19 at 2:45 PM revealed "...Poses risk of self harm...Needs secure setting with 15 minute checks, pharmaceutical stabilization and therapy..."

Medical record review of a Physician's note dated 6/11/19 at 7:11 PM revealed "...The patient is being admitted for inpatient psychiatric evaluation and treatment..."

Medical record review of a CRT Consult record dated 6/11/19 (no time documented) revealed "...[Patient #22] is endorsing SI [suicidal ideation] and earlier today voiced desire to shoot herself. Indicates anxiety and panic feelings...can't be safe and feels she is at risk for self harm...has been referred to [Hospital D]..."

Medical record review of a Nurse's note dated 6/12/19 at 9:10 AM revealed "...Received call from [named person] with CRT. States pt has been accepted to [Hospital D]..."

Medical record review revealed Patient #22 was transferred to Hospital D on 6/12/19 at 9:58 AM (51.5 hours after arrival to the ED).

Review of the census records for the geriatric psychiatric unit revealed on 6/10/19, 6/11/19, and 6/12/19 the facility had vacant beds available for female patients on the unit.

3. Medical record review revealed Patient #27, a 75 year old female, presented to Hospital A's ED on 5/2/19 at 6:04 PM for complaint of altered mental status. Continued review revealed the patient had a MSE initiated by a Physician on 5/2/19 at 6:24 PM.

Medical record review of a CON dated 5/2/19 at 6:27 PM revealed "...Patient has severe depression with suicidal thoughts. She states she wishes to end her life by cutting herself and letting herself bleed out...requires treatment for depression...poses a risk to herself if sent home..."

Medical record review of a Physician's order dated 5/2/19 at 7:23 PM revealed "...Consult Orders - Crisis Response Services..."

Medical record review of a Nurse's note dated 5/2/19 at 7:44 PM revealed "...crisis [CRT] notified of eval [evaluation]..."
Medical record review revealed Patient #27 was transferred to Hospital E on 5/3/19 at 8:54 AM (14 hours and 50 minutes after arrival to the ED).

Review of the census records for the geriatric psychiatric unit revealed on 5/2/19 and 5/3/19 the facility had vacant beds available for female patients on the unit.

4. Medical record review revealed Patient #30, a 70 year old female, presented to Hospital A's ED on 5/30/19 at 10:24 PM for complaint of taking an unknown number of Hydrocodone (pain medication), Ambien (sleeping pill), and other unknown medications. Continued review revealed a MSE was completed by the Physician on 5/30/19 at 10:32 PM.

Medical record review of a CON form completed by the facility dated 5/30/19 at 10:32 PM revealed "...Patient brought to Emergency Department after intentional overdose of chronic medications including controlled substances. Patient has history of depression and remains confused at this time. Patient is, at this time, a danger to herself and others...Patient unable to maintain personal safety at this time and remains a danger to herself...Patient requires immediate inpatient treatment..."

Medical record review of a Physician's note dated 5/31/19 at 12:27 AM revealed "...need to transfer to another facility [Hospital A] does not immediately have the required specialist..."

Medical record review of a Physician's note dated 5/31/19 at 1:58 AM revealed "...Other consultation...Case reviewed with...CRT by phone...Referrals made for psychiatric evaluation/treatment..."

Medical record review of a Nurse's note dated 5/31/19 at 2:44 PM revealed "...[Hospital E] called to decline pt at this time, MD [at facility E] states too soon after ingestion of medication..."

Medical record review of a Physician's note dated 5/31/19 at 6:34 AM revealed "...[Patient #30] Transfer ordered to Other Psych Hospital [Hospital C]. Diagnoses are Major depressive disorders...poisoning by other antiepileptic and sedative-hypnotic drugs, intentional self-harm..."

Medical record review revealed Patient #30 was transferred to Hospital C on 5/31/19 at 12:22 PM (14 hours after arrival to the ED).

Review of the census records for the geriatric psychiatric unit revealed on 5/30/19 and 5/31/19 the facility had vacant beds available for female patients on the unit.

Telephone interview with the Geriatric Psychiatric Program Director on 11/8/19 at 9:45 AM revealed the geriatric psychiatric unit does not admit involuntary admissions/committals to the unit.

Interview with the Risk Manager and the ED Director on 11/8/19 at 10:00 AM, in the Administrative Conference Room, confirmed the facility failed to admit Patient #12, Patient #22, Patient #27, and Patient #30 to the geriatric psychiatric unit on days when the unit had available beds for patients with psychiatric related conditions.