HospitalInspections.org

Based on a review of policy, other documentation, emergency department records for persons with emergency medical conditions, and census lists for the behavioral health unit, it is revealed that 1) the hospital has exclusionary criteria for admission to the Behavioral Health Unit which includes "Problems with mood," "MR" (mentally retarded) and "Autistic" patients; 2) Patients #2 and #3 were not admitted to the behavioral health unit though the unit had the capability and capacity to provide stabilizing treatment.
The behavioral health unit of the hospital is a locked unit which accepts voluntary and involuntary admissions.
A policy entitled "Mental Health Admission Criteria" (MHAC) revised 4/13 reveals a section entitled "Exclusion Criteria Guidelines" gives exclusions in part as follow: 1) Problems with mood, and/or that are due to substance abuse, severe mental retardation, dementia, autism. "
A Behavioral Health Unit (BHU) form entitled "Information From Review of Packets From Outside Hospitals" revealed a place to fill in "Any Exclusion criteria, MR, Dementia, Autism." Interview with the BHU Manager revealed that the BHU has taken persons with intellectual disabilities, and that admission is considered on a case by case basis. The MHAC revealed that all admissions must have an Axis I psychiatric diagnosis. However, there is no mention in the policy, the Review of Packets form, or during interview, that an emergency medical condition (EMC) was a factor for admission.
Patient #2 is a late middle-aged male who presented to hospital #2 in late October 2013 on an emergency petition for erratic, bizarre behavior in which he demonstrated paranoid behaviors, such as boarding himself into his home. Additionally, he was reported to have expressed suicidal thoughts. Further, patient #2 had been acting aggressively, so there was a concern of homicidal ideation as well.
On the day of presentation to the ED of hospital #2, the BHU of MedStar Southern Maryland Hospital had 12 available beds; 6 of them male beds. However, patient #2 was not accepted to the BHU of MedStar Southern Maryland Hospital, and no rationale is found for that decision.
Patient #3 was a male in his thirties who had a recent psychiatric hospital stay, and who presented via police to the emergency department (ED) of MedStar Southern Maryland Hospital in late October 2013 due to command hallucinations telling him to kill people. Patient #3 was noted to have a supply of knives at home, and to be noncompliant with medication.
A packet of clinical information went to the behavioral health unit (BHU) of MedStar Southern Maryland Hospital for possible admission. A cover page of this packet reveals a hand-written notation which states in part, " ...acuity too high. " It is unclear if this notation refers to the acuity of the patient, or the unit. If in reference to the unit, no accompanying substantive data supports that the unit had a high acuity that day. Review of the unit census reveals that of 28 possible beds divided between male and female patients, 17 of the beds were unoccupied at the time of patient #3's emergency department presentation, 7 of the 17 unoccupied beds are designated male beds. Therefore, and though MedStar Southern Maryland Hospital did not admit patient #3, the BHU had the capability and the capacity to provide stabilizing treatment for patient #3 who was found to have an emergency medical condition.

A request to review the behavioral health unit log showing the hospital emergency department and outside hospital emergency departments requests for patient admissions to the behavioral health unit revealed: 1) that there is no actual log, and 2) there is little documentation of hospital requests, decision-making and rationales for decisions to admit or deny admission.

The hospital maintains a log of all patients presenting to the Emergency Department. However, decision to admit to the behavioral health unit (BHU) from the emergency room or from transfers from other emergency rooms are deferred to the staff of BHU. There was no documentation or log to determine if admission to that unit were handled in accordance with EMTALA. Interview with Administration on 12/5/2013 revealed that a log was in use for a brief time approximately eight months ago but was later discontinued.

There was little documentation of referrals which were noted to be in various states of completeness. Some of the documentation revealed a cover page with a hand-written "not accepted." Still other documentation revealed no reference as to the disposition of the referral. Based on this lack of referral information and documentation, it is not possible to ascertain how many referrals were made and over what time period. It was impossible to verify that the hospital accepted patients when they had the capability and capacity to do so. Additionally, the decision-making documentation related to the available examples of referrals is not always indicated as to whether a patient was accepted or denied, and by what rational. Consequently, the hospital failed to maintain a log of referral requests for the BHU for those patients with emergency medical conditions requesting admission.