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Based on review of Processing Emergency Room (ER) Referrals, the Intake and Marketing System Manual, the Referral Call Sheet, the Intake Activity Log, review of clinical records, and interview, it was determined the facility failed to accurately and completely record Patient #1's intake presentation into the Intake Activity Log. Failure to enter Patient #1's name into the Intake Activity Log did not allow the facility to track Patient #1's presentation and treatment. The failed practice affected Patient #1 and had the likelihood to affect all patients presenting to the Assessment and Referral (A and R) Department. Findings follow:

A. Review on 03/20/23, the (Receiving Facility #1's) Processing ER Referral instructions showed the following:
1) When a packet was received through the E-fax or analog fax machine, quickly open the fax, and call the referring Emergency Department (ED).
2) Review the fax for clinical appropriateness or for exclusionary condition.
3) The nurse used the "zone" method to identify the patient qualification.
a. Green zone will accept patient who was dangerous to others and blood alcohol level was trending down.
b. Yellow zone required additional review and information (recent use of restraints) to be entered in the intake form.
c. Red zone was exclusionary conditions and cannot be treated at the facility.

B. Review on 03/20/23, the (Receiving Facility #1's) Intake and Marketing System manual, dated July 2015, showed the manual provided the user with the tools and explanations needed to complete an inquiry call, admission and advanced functions including editing an existing account, discharging, or transferring a patient and reconciling the inpatient census.

C. During an interview on 03/20/23 at 1:00 PM, when Surveyor asked the (Receiving Facility #1's) Assistant Director of Assessment and Referrals (A and R) the process for each call, he stated "For each call or fax referral, a referral sheet was filled out and that information would be entered into the electronic Intake system."

D. Review on 03/20/23 of the (Receiving Facility #1's) Referral Call Sheet and Intake Activity Log for November 2022 showed the following:
1) There was no evidence Patient #1 was placed on the Intake Activity Log after the initial referral on 11/29/23 at 11:16 PM.
2) The Referral Call sheet dated 11/29/22 at 11:16 PM showed the reason for decline/non-admit was due to assault/aggressive behavior.

E. During an interview on 03/21/23 at 9:30 AM, the Director of A and R confirmed the findings in A through D.

Based on clinical record review, policy review, and interview, it was determined the facility failed to ensure one of one (#1) patient received an appropriate and timely medical screening exam (MSE). Failure to provide an appropriate and timely MSE did not ensure the facility was aware of whether Patient #1 had an emergency medical condition, which caused a delay in medical treatment. The failed practice affected Patient #1 and had the likelihood to affect all patients presenting to the Admissions and Referral (A and R) Department. Findings follow:

A. Review of Receiving Facility #1's "Processing ER (Emergency Room) Referral" instructions showed the following:
1) When a packet was received through the E-fax or analog fax machine, quickly open the fax, and call the referring ER.
2) Review the fax for clinical appropriateness or for exclusionary condition.
3)The nurse used the "zone" method to identify the patient qualification.
a. Green zone will accept patient who was dangerous to others and blood alcohol level was trending down.
b. Yellow zone required additional review and information (recent use of restraints) to be entered in the intake form.
c. Red zone was exclusionary conditions and cannot be treated at the facility.

B. Review Receiving Facility #1's policy titled "Admissions Criteria, Non-Admission Criteria and Administrative Discharge and Transfers" revised 07/21 showed the following:
1) Receiving Facility #1 were to treat all persons without regard to race, color, creed, religion, sex or national origin including assignments or transfers within the facility.
2) Patients will be medically stable as determined by the nursing assessment at the time of admissions.

C. During an interview on 03/21/23 at 9:30 AM, the Director of A and R confirmed the findings in A and B.

D. During a phone interview on 03/30/23 at 9:00 AM, the Surveyor asked the Officer #1 to provide the details during transport of Patient #1 from Referring Facility to Receiving Facility #1 with the following:
1) Officer #1 stated, "He decided to continue to (Receiving Facility #1) and sat in the parking lot for approximately 4 hours."
2) Officer #1 stated, "A young black male came to the vehicle and spoke to Patient #1 and informed him (Officer #1) they were trying to 'work it out.'"

E. During a phone interview on 04/03/23 at 2:30 PM, the Referring Facility Compliance Officer (CO) stated the (Referring Facility) CO contacted the (Receiving Facility #1) Chief Executive Officer (CEO). The CO stated the CEO informed them the Receiving Facility #1 has the right to screen and refuse admission after they screen the patient.

F. There was no evidence Patient #1 received an MSE at Receiving Facility #1.

G. The Assistant Director of A and R confirmed in an interview on 03/21/23 at 9:30 AM that Patient #1 did not receive an MSE at Receiving Facility #1.

Based on policy and procedure review, medical record review, and interview, it was determined the facility failed to accept an appropriate transfer for one of one (#1) patient requiring specialized psychiatric services not offered by the transferring facility related to (R/T) potential aggression. By not accepting Patient #1 the facility delayed the specialized treatment needed for Patient #1. The failed practice had the likelihood to affect any patient needing the specialized services provided by the facility for acute psychiatric treatment. Findings follow:

A. On 03/20/23, review of Receiving Facility #1's "Processing ER Referral" instructions showed the following:
1) When a packet was received through the E-fax or analog fax machine, quickly open the fax, and call the referring ER.
2) Review the fax for clinical appropriateness or for exclusionary condition.
3)The nurse used the "zone" method to identify the patient qualification.
a. Green zone will accept patient who was dangerous to others and blood alcohol level was trending down.
b. Yellow zone required additional review and information (recent use of restraints) to be entered in the intake form.
c. Red zone was exclusionary conditions and cannot be treated at the facility.

B. On 03/20/23, review of Receiving Facility #1's Intake Activity Log for November 2022 showed no evidence Patient #1 was placed on the Intake Activity Log after the initial referral denial on 11/29/23 at 11:16 PM.

C. During an interview on 03/20/23 at 1:00 PM, when Surveyor asked Receiving Facility #1 Assistant Director of Assessment and Referral (A and R) to explain the process for each call, he stated "For each call or fax referral, a referral sheet was filled out and that information would be entered into the electronic Intake system."

D. During an interview on 03/21/23 at 9:30 AM, Receiving Facility #1 Director of A and R confirmed the findings in A through C.

E. On 04/03/23, review of Patient #1's clinical record from the Referring Facility dated 11/29/23 to 11/30/23 showed the following:
1) On 11/29/22 at 6:20 PM, Patient #1 was admitted to the Referring Facility's Emergency Room (ER) with a behavior of agitated, hostile and suicide precautions.
2)On 11/29/22 at 6:55 PM, Patient #1 was hostile with SO (Sheriff Officer) and was placed in handcuffs on wrist and ankles.
3) On 11/29/22 at 8:07 PM, Patient #1 was calm and cooperative. SO removed handcuffs.
4) On 11/29/22 at 8:34 PM, Crisis Intervention screening showed patient to be calm and cooperative during the assessment. Recommendation for acute placement and the counseling center approved a three-day contract (payment source).
5) On 11/29/22 at 9:34 PM, the Referring Facility ER RN faxed referral to Receiving Facility #1.
6) On 11/29/22 at 10:08 PM, the Referring Facility ER RN called Receiving Facility #1 to confirm receipt of the referral. Receiving Facility #1 informed the Referring Facility ER RN the patient's blood alcohol level needed to be less than (<) 100.
7) On 11/30/22 at 1:15 AM, the Referring Facility ER RN called Receiving Facility #1 informing Patient #1's blood alcohol level was 120. Receiving Facility #1 informed the Referring Facility ER RN the patient's blood alcohol level needed to be less than (<) 100.
8) On 11/30/22 at 3:33 AM, the Referring Facility ER RN called Receiving Facility #1 informing Patient #1's blood alcohol level was 73 and was requested to re-fax paperwork to Receiving Facility #1 to be reviewed.
9) On 11/30/22 at 4:28 AM, Referring Facility ER RN called Receiving Facility #1 and informed Referring Facility ER RN that Patient #1 did not have active insurance and without counseling service getting contract days, the patient would not be accepted to Receiving Facility #1.
10) On 11/30/22 at 4:40 AM, Referring Facility ER RN called Receiving Facility #1 and was informed Patient #1 was accepted by Receiving Facility #1 on-call (Named) Psychiatrist but could not arrive until after shift change at 8:00 AM.
11) On 11/30/22 at 4:48 AM, the Referring Facility ER RN called Receiving Facility #1 and gave Receiving Facility #1's Unit RN report. The Receiving Facility #1 RN requested a call as the Patient was being discharged from the ER.
12) On 11/30/22 at 6:05 AM, the Referring Facility ER RN called Receiving Facility #1 and gave the Unit RN notification Patient #1 left the ER and was transported via the Sheriff's Officer (SO).
13) On 11/30/22 at 8:58 AM, the Referring Facility ER RN received a call from Receiving Facility #1 requesting the contact phone number of the transport team.
14) On 11/30/22 at 7:45 AM, the Referring Facility ER RN received a call from the SO dispatcher requesting a copy of the court order. The dispatcher reported to the Referring Facility ER RN that Patient #1 was denied admittance after arrival to Receiving Facility #1 .

F. During a phone interview on 03/30/23 at 10:18 AM, the Referring Facility Chief Nursing Officer (CNO) confirmed the findings in E.

G. During a phone interview on 03/30/23 at 9:00 AM, the Surveyor asked the Officer #1 to provide the details during transport of Patient #1 from Referring Facility to Receiving Facility #1 with the following:
1) Officer #1 stated, "Patient #1 was calm and cooperative during transportation."
2) Officer #1 stated, "Approximately 15 miles from (Receiving Facility #1), he received a call from (Receiving Facility #1) informing him to "Turn around and take the patient back" to the (Referring Facility)."
3) Officer #1 stated, "He decided to continue to (Receiving Facility #1) and sat in the parking lot for approximately 4 hours."
4) Officer #1 stated, "A young black male came to the vehicle and spoke to Patient #1 and informed him (Officer #1) they were trying to 'work it out.'"
5) Officer #1 stated, "While waiting in the parking lot, the (Referring Facility ER) RN notified them another facility (Receiving Facility #2) had accepted Patient #1."
6) Officer #1 stated, "While in route approximately 30 minutes from (Receiving Facility #2), (Receiving Facility #1) called stating they had decided to accept the patient.
7) Officer #1 stated, "At that point, I was closer to (Receiving Facility #2) than (Receiving Facility #1)."

H. During a phone interview on 04/03/23 at 2:30 PM, the Referring Facility Compliance Officer (CO) stated the following:
1) The (Referring Facility) ED Manager contacted the CO about the refusal of admission after report from the (Referring Facility) ED RN to (Receiving Facility #1) RN had been conducted.

2) The (Referring Facility) CO contacted the (Receiving Facility #1) Chief Executive Officer (CEO). The CO stated the CEO informed them the Receiving Facility #1 has the right to screen and refuse admission after they screen the patient.