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Based upon reviews of the hospital's revised policies and procedures (submitted as part of hospital's Plan of Correction for survey 10/27/10), Intake/Inquiry Forms (for January 1-24, 2011), Admit/Referral Log (for January 1-24, 2011), Governing Body and Medical Executive meeting minutes, and Administrative interviews, the hospital failed to meet EMTALA requirements as defined in CFR 489.24 by failing to accept transfers from other hospitals for patients who required inpatient psychiatric treatment for 5 of 5 (# F6, F7, F8, F9, F10) who required hospital admission, when the hospital had the capacity and capability to provide the necessary treatment.

Based upon reviews of the hospital's revised policies and procedures (submitted as part of hospital's Plan of Correction for survey 10/27/10), Intake/Inquiry Forms (for January 1-24, 2011), Admit/Referral Log (for January 1-24, 2011), Governing Body and Medical Executive meeting minutes, Administrative interviews, reviews of medical record, daily floor census sheets, and nurse staffing schedules, the hospital failed to accept transfers of patients from other hospitals who required inpatient psychiatric treatment when the hospital had the capacities and capabilities to accept the patients. This was evident for 5 of 5 patients reviewed (# F6, F7, F8, F9, F10). Findings:

Review of Executive Committee and Governing Body meeting minutes dated 12/09/10 revealed the hospital's revised policies/forms/logs were submitted for approval on December 9, 2010. Continued review of the meeting minutes revealed the revised policies/forms/logs were all approved and implemented on 12/10/10.

Review of a form/log titled "Physicians Behavioral Hospital Admit/Referral Log", for the dates 01/02/11 through 01/24/11 revealed on 01/05/11, there were 5 referrals (patient #s F6, F7, F8, F9, F10); however, none were admitted on 01/05/11 even though the daily floor census revealed there were 9 available beds and staff were present.

Review of the daily floor census sheet, dated 01/05/2011, revealed there were 5 inpatients, leaving 9 unoccupied beds. Review of the nursing staff schedule, dated 01/05/2011, revealed on the 7a-3p shift there was 1 Registered Nurse (RN), 1 Licensed Practical Nurse (LPN), 2 MHTs (Mental Health Technicians); 3p-11p shift 1 RN, 1 LPN, 2 MHTs; and on the 11p-7a shift 1 RN and 2 MHTs.

Review of the nursing staff schedule dated 01/01/11 through 01/26/11 revealed the same staffing as indicated for 01/05/2011 was maintained for all shifts for the dates of 01/01/11 through 01/26/11. Review of the daily floor census and daily nursing schedule/pattern revealed the hospital maintained the nursing personnel pattern regardless of the census.

Review of the Admit/Referral Log, dated January 2011, revealed on 01/05/11 there were 5 patient referrals entered on the log with their diagnoses varying from Suicidal Ideation (SI), overdose attempt, and paranoia/psychosis.

Review of Physicians Behavioral Hospital's Admit/Referral Log, dated January 5, 2011, revealed SF 1 DON documented, under the "Reason for Decline" for patient #s F6, F7, F8, F9, and F10, "no OBS (observation) beds avail (available)".

Interview, 01/24/11, with SF 1 Director of Nursing (DON), SF 3 Assistant Administrator, and SF 5 Director Social Services revealed the 5 referred patients all had diagnoses that (under the hospital's definition of "psychiatric crisis") warranted admission into an Acute Close Observation Bed. According to the interview, on 01/05/11 the hospital did not have an available Acute Close Observation Bed.

Review of the hospital's revised policy PE.006, (approved by the Medical Executive Committee and Governing Body 12/09/10 and implemented 12/10/10), titled "Acute Close Observation Beds" revealed the following: "Policy It is the policy that each patient shall receive care in the setting most appropriate to his or her needs, taking into consideration of the need to ensure the safety of each patient and the need to preserve the integrity of the therapeutic milieu. Procedure 1. PSYCHIATRIC CRISIS PATIENT CALLS These calls may come...from an Emergency Room in the area. 2. PSYCHIATRIC CRISIS is defined as a condition when a patient is in imminent danger of harm to self or others or gravely disabled due to a treatable psychiatric condition. 3. No patient in such PSYCHIATRIC CRISIS shall be declined for admission and treatment for stabilization due to financial resources. 4. Physicians Behavioral Hospital has designated approximately 15% of bed capacity (2 beds) as Acute Close Observation Beds. All PSYCHIATRIC CRISIS patients must be admitted to the Acute Close Observation Beds until stabilized...5. NON-CRISIS PATIENT CALLS: All patients requesting admission that are NOT in crisis but meet admission criteria are expected to have guaranteed payment source. Other wise these patients may be declined for admission from Hospital Administration..."

Interview, 01/25/11, with SF 1 Director of Nursing (DON) and SF 3 Assistant Administrator revealed the hospital had determined Rooms #1 and #2 would be utilized as the Acute Close Observation Beds. SF 1 DON further stated the purpose of the observation beds were for patients who were in "psychiatric crisis" whether they were new admissions or if one of the hospital's inpatients developed a "psychiatric crisis".

An interview, on 01/25/11, with SF 1 DON revealed upon further questioning as to why none of the 5 referred patients were admitted, he replied "not sure". SF 1 DON reviewed the Admit/Referral Log and Intake/Inquiry sheets for 01/05/11. Review of the logs revealed SF 1 DON had documented "No admit beds available" as the reason for declining admission for the 5 patient referrals when there were 9 available beds (one of which was an Acute Close Observation Bed). Continued interview with SF 1 Director of Nursing (DON) revealed when questioned as to why none of the 5 referred patients were admitted as they met: 1) the hospital's admission criteria; 2) the hospital's definition of a patient in "psychiatric crisis"; and 3) the hospital had available beds and staff, he stated he could not answer why the patients were declined admission.

Observations made on 01/24/11 of the patient care units revealed Rooms #1 and 2, along with Rooms 13 and 14 were the closest in proximity to the nurse's station. Interview, 01/25/11, with SF 1 DON and SF 3 Assistant Administrator confirmed the hospital had decided to use Rooms 1 and 2 as the Acute Close Observation Beds. It should be noted these rooms were not listed in policy PE.006 as the only Acute Close Observation Beds.

Review of the daily floor census, dated 01/05/11, revealed Room #2 was unoccupied. According to SF1 DON's statement, Room #2 was utilized as an Acute Close Observation Bed, therefore the hospital did have an available acute close observation bed and could have admitted at least one of the five (1 of the 5) patient referrals.

Interview on 01/25/11 with SF 1 DON, revealed he stated the hospital did not have clinical/financial information on the patients (#s F6, F7, F8, F9, F10) who were referred on 01/05/11. Interviews, 01/26/11, with SF 1 DON, SF3 Assistant Administrator, and SF6 Director of Social Services revealed when questioned if the reason the 5 referred patients (01/05/11)were refused admission was based on their financial class, SF3 Assistant Administrator stated the hospital had admitted patients who were listed as "indigent or free care". Continued questioning of the above staff members regarding the reason for the declined admission on the 5 patients revealed SF 1 DON stated he was not aware of the patients' financial class and could not offer an explanation. SF 1 DON stated he was at a loss as to why the 5 referred patients were not admitted.