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Based upon review of the facility admission logs and interview with staff the facility could not provided evidence that this requirement was met as follows:

Findings:

a. Based on review of admissions logs it was observed there were several central logs for San Antonio State Hospital admissions there was a "call in log", "walk in log", "court order/emergency detention log. The" Admissions Tracking and Registration Log" included the categories "TIME IN, PATIENT NAME, DOB, COUNTY, ADMIT TO TIME OUT, REFER TO AND COMMENTS". There was no evidence of categories for refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharge.

b. Interviewed San Antonio State Hospital (SASH) staff #4, director of quality management at 10:30am on May 3, 2010 and again at 1:00pm on May 4, 2010 reviewed the admission logs, also known as their central logs. Staff member could not show evidence that the logs reviewed contained categories for refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged. There was no evidence provided to conclude that this requirement was met.

Based upon hospital policies, review of medical documentation and interview with staff at San Antonio State Hospital (SASH), a psychiatric facility and the ambulance crew that transferred a 36year old female patient to this facility on the early morning of March 30, 2010 there was no evidence provided that the patient received an appropriate psychiatric evaluation/screen to rule out a psychiatric emergency. This requirement was not met as follows:

Findings:

a. Policy SOP#200-1 last revised 04/27/09 Guide for Admission of Patient to San Antonio State Hospital:
On page 2 of 6 Admission Determinations it states "All individuals presenting for admission to the hospital shall be evaluated by the physician for medical necessity. The findings shall be documented for medical necessity. The findings shall be documented on the Psychiatric Evaluation form (Exhibit B). At a minimum the process shall include documentation of the following:
Reason for referral of admission;
Description of legal situation;
Brief history pertinent to the current admission request;
Provisional diagnosis (if any)
A determination of whether the prospective patient meets the criteria for admission to SASH
A medical recommendation, based on the findings and conclusions of the evaluation that shall indicate whether the
patient may be
Treated in a less restrictive setting ... "

The same policy further states " In the event the patient is denied admission to the facility, the Psychiatric Evaluation shall be kept on file in the Admissions Office as a record of contact.. " and When an admission is refused, an alternate disposition shall be recommended with regards to the needs of the applicant, and the responsible Mental Health Authority (MHA), as appropriate, shall be contacted and advised of the recommendation within twenty-four (24) hours of the denial by Physician Officer of the Day (OD) or Medical Director of Admissions.

It also states: " When a voluntary patient or a patient who arrives on EAD is denied admission, a Psychiatric Evaluation Form, (CWS 3-1 (Exhibit G) shall be completed, The form shall include the reason for denial, a short narrative mental evaluation, and the agency to which the patient was referred. The physician will also document that the patient was examined and that an emergency medical condition did or did not exist. The physician will also call the referring agency and notify them of the referral "

Verbally the physician said he performed a psychiatric evaluation for the patient of concern, but there was no physical evidence of a psychiatric evaluation document being completed. As per these two policies.

b. Interviewed staff #4, RN, director of quality management at 10:15am on May 3, 2010 in the administration conference room who provided inpatient medical record documents of patient of concern She said all patients should be evaluated to decide if they meet the admission criteria. She conducted research to find evidence of the psychiatric evaluation of this patient during their first visit to the facility on the early morning of March 30, 2010. Staff #4, director of quality management was not able to show evidence of a documented completion of a psychiatric evaluation conducted on the 36 year old female during her first visit to the facility at 3:50am on March 30, 2010. The only information that was documented and received by the Department State Health Service (DSHS) investigators showing evidence that arrived at the facility in the early morning of March 30, 2010 was the patient ' s logged in name on the " ADMISSIONS TRACKING AND REGISTRATION LOG " which showed the patient of concern (36y/o female) coming in at 3:50am on 3/30/10 and time out as 4:12 am on 3/30/10. The comments section stated " Sent Back (No comm. paper)", meaning no commitment paperwork. The other documentation showing evidence that the patient arrived at the facility was an " ADMISSIONS CHANGE OF SHIFT REPORT " dated on 3/29/10 from the 1100pm -0700 shift stated problem encountered as:

A 36 year old female patient came in via ambulance from Jacksonville. The patient had no commitment documents. Per San Antonio State Hospital staff # 8, MD was sent back to their emergency room.

c. Interviewed San Antonio State Hospital Staff # 7, Medical Director for Admissions at San Antonio State Hospital (SASH) at 11:25am on May 3, 2010 on the admission unit of SASH. The hospital admission procedure was reviewed with him. Staff #7, MD explained that a physician performs a standard evaluation on each person presenting to the admissions office. This is documented on a standard evaluation form and is done in the admissions room. A psychiatric evaluation form is filled out on every person who presents, whether they are admitted or not. If a person does not meet admission criteria they are returned to their point of origin. Every person who presents, whether admitted or not, is logged in on a log in the admissions office to determine if a psychiatric emergency exists and to satisfy the Emergency Medical Treatment and Active Labor Act (EMTALA).

d. Interviewed San Antonio State Hospital (SASH) staff # 8, MD, on duty psychiatrist at 1:30pm on May 3, 2010 in the administration conference room. Staff #8, MD said he was the admitting and assessing psychiatrist when patient of concern, 36year old female was bought to the facility by an ambulance crew on the early morning of March 30, 2010. He said the patient did not have any emergency detention or court orders for her to be at the facility and at that she in his opinion was not medically stable. He said she was incoherent. During his evaluation of her he asked her if she wanted to be an inpatient at the facility she told him " no " that she did not want to be admitted. He said she was" out of it" and was still under the influence of whatever she ingested. He said he called the facility and spoke to someone that he could not remember the name but knew it was not the physician at Jackson Healthcare center and explained to that person that he was sending the patient back to the facility with the ambulance crew that brought her to SASH to be evaluated because she did not have the correct paperwork. The patient was not alert, oriented and conscious enough to make a sound decision at this time; thus was not medically stable. He said that he had worked at San Antonio State Hospital (SASH) for many years and he always explain to the physicians from the other facilities who try to send their patient to SASH that the patient needs to be on an emergency detention or court order to be admitted to the facility and if they are coming in voluntary they have to want to be admitted be alert/conscious enough in their ability to make a decision of wanting to be admitted if they are voluntary. The facility cannot make them or force them to be admitted when they do not want to be admitted. He said many facilities do not understand that the patient is going to be evaluated by SASH. All of the criteria for admission must be met before the patient is admitted. He said but in this case the patient was not an emergency detention and did not have a court order and when asked during the evaluation if she wanted to remain at the facility she responded by saying " no " she did not want to be a patient. At that point SASH obligation ended since he could not force a voluntary patient to stay at the facility. Staff #8, MD was asked if he conducted and filled out a psychiatric evaluation and completed a screen on the patient since their policy required " All " patients to have a psychiatric evaluation filled out. He said he did conduct and documented a psychiatric evaluation on the 36 year old female patient.

d. Interviewed ambulance transportation staff #13, emergency medical technician at 1:40pm on May 6, 2009 via telephone. Staff #13 was one of the two ambulance transportation staff that transported the patient of concern 36 year old female from Jackson Healthcare Center, Edna, Texas to San Antonio State Hospital (SASH) at 1:00am on May 30, 2010. Staff #13 said when they arrived at SASH they went to the admission unit and first spoke to a nurse who had no ideal this patient was coming to their facility. She asked if the patient had a court order or emergency detention papers. The ambulance staff gave her the paperwork they received from Jackson Healthcare Center, Edna, TX. A court order, warrant or emergency detention paper was not included in the paperwork given. The nurse explained that they could not admit this patient if she did not have the proper paperwork. A physician came out and spoke to the patient and ambulance crew. The physician seemed kind of rushed and he told the ambulance crew the same that the facility could not admit the patient unless she was under court order and/or had emergency detention paperwork and have police escort. Since the patient did not come to the facility with the proper paperwork, the only way she could be admitted is if she volunteered to be admitted. He said at the time the patient was still kind of lethargic but staff #13 thought she was conscious enough to answer questions. Staff #13, said he witnessed the physician ask her if she wanted to be admitted and twice she said " yes " that she wanted to be admitted. Staff #13 said the patient showed concern about her job but never from what they witness did the patient say that she " did not " want to be admitted. The doctor told her that he did not think her thought pattern/consciousness was clear/alert enough to make that determination because she was still under the influence of whatever drug she ingested. Staff #13 explained that from his perspective and what he heard between the interaction of the doctor and the patient, the doctor did not ask the patient many questions which he thought was kind of strange. He said it appeared to him that the doctor was a little angry because the patient came to the facility without the proper paperwork and mode of transportation. The doctor went into the administration office at least twice but the ambulance staff did not know during those times if the physician wrote notes on the patient or not. They were unsure if the doctor called anybody at Jackson Healthcare about her disposition. The doctor came out and asked the ambulance crew to transport the patient back to Jackson Healthcare Center, Edna, TX because the patient did not have the right paperwork. The ambulance crew transported the patient back to Jackson Healthcare center. Staff #13 said the patient and ambulance crew stayed at SASH for about 30 minutes (estimation) total before transporting the patient back to Jackson Healthcare center.

e. Reviewed a total of 22 admissions records consisting of admittances and denials of court orders, walk- ins, voluntary and involuntary patients and 2 out of the total of 22 (9%) admission records reviewed did not have documented psychiatric evaluations as required per policy. The two admission records that did not have a psychiatric evaluation were both of patients whose admissions were denied for admission. One was the patient of concern 36 year old female, and the second one was of patient #10 a 39 year old male who was voluntary walk-in on March 4, 2010 at 9:45pm. An admission Walk-in form was filled out on the patient. The patient was logged into the admission log but a documented psychiatric evaluation form was not present for the patient. It was confirmed by staff#7, the Medical Director of Admissions, at 2:00pm on May 4, 2010 that the Admission Walk in Form was not a psychiatric evaluation. A psychiatric evaluation was not in the patient ' s admission record as per hospital policy.