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Based on review of medical records, patient assessment log, staff interviews, recording of a telephone call between hospital #1 and #2, and medical staff rules and regulations, it was determined the hospital failed to comply with 489.24, as evidenced by failing to:

489.24(a) Tag 2406

a. ensure 18 of 23 patients had a medical screening examination (MSE) conducted by qualified medical personnel who were determined qualified by the medical staff rules and regulations and met the requirements of 482.55 conditions of participation for emergency services (Pt #'s 2, 3, 4, 6, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 and 22); and

489.24(f) Tag 2411

a) failed to accept Pt #1 requiring admission for an emergency psychiatric condition of suicidal ideation while having the capacity and capability to treat Pt #1.

The cumulative effect of these deficient practices resulted in the hospital's failure to be in compliance with EMTALA requirements.

Based on observation during tours and interviews with staff, it was determined the hospital failed to post signs specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital participates in the Medicaid program under a State plan approved under Title XIX.

Findings include:

A tour of the Assessment and Referral Department was conducted on 07/24/12 at 0900 hours, with the Director of Patient Services.

The following information was obtained through observation and interview:

Walk-in patients enter through the hospital's main lobby and check in with the receptionist at the desk. The patient waits in the lobby until called to the Assessment and Referral area for an evaluation. No signs specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor were posted in the lobby.

The Assessment and Referral Department, located behind the lobby and through a door to the hallway leading to this Department, contained four examination rooms located on the north side of the hall. The staff had an entrance into their office area opposite the exam rooms on the south side of the same hall. The hall was approximately 5 feet wide. This area had one sign typed on an 8 1/2 x 11 inch paper, located by the staff entrance into their office area for the Assessment and Referral Department. The sign contained: "It's The Law! If you have a medical emergency or are in labor, you have the right to receive, within the capabilities of this hospital's staff and facilities: An appropriate medical screening examination. Necessary stabilizing treatment (including treatment for an unborn child), if necessary, an appropriate transfer to another facility. Even if you cannot pay or do not have medical insurance or you are not entitled to Medicare or AHCCCS." The patient intake rooms were on the opposite side of the hall. The sign was not in a conspicuous place and the letters could not be read by the Surveyors from a distance of 20 feet.

Based on review of medical records, policies and procedures, medical staff rules and regulations, and interviews with staff, it was determined the hospital failed to ensure 18 of 23 patients had a medical screening examination (MSE) conducted by qualified medical personnel who were determined qualified by the medical staff rules and regulations and met the requirements of 482.55 conditions of participation for emergency services (Pt #'s 2, 3, 4, 6, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 and 22).

Findings include:

The medical staff rules and regulations required: "...Medical Screening...B. Qualified Medical/Psychiatric Personnel...Specific staff member(s) appointed by the Medical Staff and approved by the Governing Body in the following positions are authorized to perform medical screening and stabilization. Physician...Allied Health Professionals privileged to admit and treat patients...Registered Nurse...Licensed Masters Level Social Worker...."

A review of 23 patients revealed that 18 did not have a MSE by a qualified medical person (QMP) approved by the Governing Body to conduct a MSE.

Patient #2, had an MSE by a Licensed Associate Counselor (LAC).
Patient #3, had an MSE by a Licensed Clinical Social Worker (LCSW).
Patient #4, had an MSE by a LAC.
Patient #6, had an MSE by a Master of Arts Psychology (MA).
Patient #8, had an MSE by a Licensed Independent Clinical Social Worker (LICSW)
Patient #9, had an MSE by a Masters of Social Work (MSW), (not licensed).
Patient #11, had an MSE by a MSW (not licensed).
Patient #12, had an MSE by a MSW (not licensed).
Patient #13, had an MSE by a MA Psychology.
Patient #14, had an MSE by a MSW (not licensed at this time).
Patient #15, had an MSE by a MA Psychology.
Patient #16, had an MSE by a MA Psychology.
Patient #17, had an MSE by a LAC.
Patient #18, had an MSE by a LAC.
Patient #19, had an MSE by a LAC.
Patient #20, had an MSE by a MSW (not licensed).
Patient #21, had an MSE by a LAC.
Patient #22, had an MSE by a MSW (not licensed).

The Director of Assessment and Referral and the Director of Patient Care Services confirmed the 18 patients did not have a QMP, that was identified in the Medical Staff Bylaws Rules and Regulations as a "...Physician...Allied Health Professionals privileged to admit and treat patients...Registered Nurse...Licensed Masters Level Social Worker...." to conduct a MSE as required.

Based on staff interviews with Hospital #2 (referring hospital) and Hospital #1 (participating hospital with psychiatric level 1 inpatient beds), and review of Pt #1 (Target Patient) medical record, audio recording of the telephone call between Hospital #1 and #2, it was determined Hospital #1 failed to accept Pt #1 who required admission for an emergency psychiatric condition of suicidal ideation while having the capacity and capability to treat Pt #1.

Findings include:

Target patient #1 presented at another acute care hospital (Hospital #2). Hospital #2 sent a fax to Hospital #1, Aurora Behavioral Health Hospital, a level 1 inpatient psychiatric facility with Patient #1's medical record and insurance information and requested an inpatient bed for the patient. This is referred to as a "patient packet" from the referring hospital.

Review of Pt #1's medical record/case management notes from the sending hospital (#2) revealed, Nurse #15 documented the following: "...06/02/12 15:15...Received call from (name of personnel, Employee #8) from (name of Hospital #1) who states Pt is a self pay and not appropriate for their facility. Notified ED PT and BHTS attempted (Name of provider) and they are saturated, not taking voluntary pt's at this time. Per (name Employee #8), they will keep the paperwork-currently no beds available on SI unit...."

A telephone interview was conducted on 07/30/12 at 0805 hours, with hospital #2's nurse (#15) who spoke to Employee #8 at Hospital #1. She explained that Employee #8 said that the patient was not appropriate for their hospital because he didn't have insurance and when she verified saying she wants to be clear that they can't take the patient because he doesn't have insurance, Employee #8 then said they did not have beds available. She disclosed that the hospital has a recording of telephone call.

The State Agency received an audio tape of the phone call between the referring hospital (#2) and hospital #1 on 07/31/12. During the telephone conversation hospital #1 identified the patient was not appropriate for their facility since the patient was a self-pay. Employee #8 indicated the hospital did not have SI beds available at this time.

Review of the telephone conversation between hospital #1 and #2 revealed the following: "...This is (Employee #8) at (hospital #1). I was calling about (Pt #1). Apparently he's a self-pay so I don't know if he is necessarily appropriate for our facility, so maybe (Name)? (Employee #15 at Hospital #2 repeats what he said to her) And you're saying he's a self-pay? Okay so he's a self pay? He's in our ER so I know we can't screen for EMTALA. (Employee #8) Right. (Employee #15) So are you going to decline due to insurance? (Employee #8) No not necessarily we're declining um. (Employee #15) I know we tried (Name). They weren't taking voluntary earlier and it looks like (Employee #8) Okay, hmmm. (Employee #15) at 1003 they were saturated and not taking voluntary patients. (Employee #8) Un-Huh, well I can hold off for a while and see if ahh whether we have something available right now. (Employee #15) Okay, so currently, nothing, no beds available currently? (Employee #8) Nah not on our SI unit, no. (Employee #15) No beds available on SI unit. Huh, for some reason like we don't screen for insurance and we don't have him down as a self pay patient. (Employee #8) Yeah. (Employee #15) We have him as a government. Huh. Sounds good. (Employee #8) Thanks."

Employee #8 was interviewed on 07/24/12 at 1630 hours. He was asked about Pt #1's referral packet he reviewed on 06/02/12, as the intake coordinator for Hospital #1. He worked the evening shift in the Assessment and Referral Department. He could not remember the patient, and explained that he did not remember talking with the nurse and if he did call he would have told them he would review the packet and call back. He denied saying that Hospital #1 would not accept a patient because he did not have insurance.

Employees #'s 3 and 4 were interviewed on 07/24/12 at 0900 hours. Employee #'s 3 and 4 had a meeting with Employee #8 on 06/06/12, to discuss Pt #1. They explained Hospital #2 had sent a patient referral packet, requesting a bed for Pt #1. Employee #8 reviewed the packet and called Hospital #2 back and talked with the nurse. They explained he told Hospital #2 they would accept the patient and asked the nurse if they had considered other options for the patient since he was a self-pay patient and he would incur charges. He offered the name of (Name) and (Name) as options because the nurse didn't know of those options. The nurse was going to talk with the patient and call back. No further call came back from Hospital #2.

Employee #14, Director of Assessment and Referral, was interviewed on 07/25/12 at 1600 hours. He had talked with Employee #8 when he was made aware of the allegation from Hospital #2, that they had refused Pt #1 since he did not have insurance. He said Employee #8 reviewed the patient packet and determined the patient met their admission criteria. He called Hospital #2 and accepted the patient for admission and during the discussion he mentioned the patient was self-pay and told the nurse the patient would be responsible for payment. During this meeting he instructed Employee #8 not to discuss insurance or payment responsibilities as this is a "grey area." He provided information in a document titled Responding to Hospital Referral Packets that outlined the responsibilities of the intake coordinators working in the Assessment and Referral Department. He then had all of the intake coordinators sign the form indicating they received the training.

The information provided in the training included: "...1. Call the hospital the patient is at and ask to speak to the patient's nurse...2. Let them know we have a bed, get report, and accept the patient...3. Ask to speak to the patient...4. Let the patient know that when they arrive here we will have a counselor and nurse meet with them and admit them to the hospital...If they are self-pay and ask about how much it's going to cost, you can let them know that it is about $1000/day plus the doctor's fees and that our business office will work with them on payment plans...Please do not discuss insurance or cost unless you have already received report, accepted the patient, AND the patient asks you about the cost!!!...."

A Second Interview with Employee #14, the Director of Assessment and Referral was conducted on 08/07/12 at 0925 hours. The State Agency received an audio tape of the phone call between the referring hospital (#2) and hospital #1. On the audio recording hospital #1 identified the patient was not appropriate for their facility since the patient was a self-pay. The recording indicated the hospital did not have SI beds available at this time. The Director of Assessment and Referral was called to verify if the hospital had beds available at 1511 hours on 06/02/12. During the interview he identified at midnight on 06/02/12 the hospital had 6 adult beds open in the detox unit and 2 adolescent beds. When asked if they had beds in the SI unit he clarified, they only had detox beds, however, he added that they will admit a patient to detox if they are the only beds available, and then they can move the patient to the SI unit when beds are available. He was asked to verify if the hospital had beds available at 1511 hours on 06/02/12, and he indicated he would call back with this information. The State Agency received a telephone message from Employee #14, on 08/08/12 at 1000 hours. He verified at the time of the Shift Census Report filled out between 1300 and 1500 hours on 06/02/12, the hospital had 1 adolescent bed, 2 adult mental health beds and 8 detox beds. The shift report did not indicate the anticipated discharges or patients currently being assessed in the Assessment and Referral area.

The Director of Quality/Risk Management called on 08/08/12 at 1015 hours and conveyed that on 06/02/12 at 1500 hours the hospital had 1 adolescent bed, 2 adult mental health beds and 8 adult detox beds available. She was asked if staff were available to care for those additional patients and she verified they had staff and were currently staffing to a census of 60.

Review of the Patient Assessment log for the entire 24 hours on 06/02/12, revealed the hospital admitted 6 patients that day. One patient was admitted at 0235 hours; the second patient was admitted at 1100 hours; the third patient was admitted at 1550; the fourth patient was admitted at 2110; the fifth patient was admitted at 2120; and the sixth patient was admitted at 2340. The 0235; 1100; and 1550 patient admissions arrived via ambulances according to the Assessment Log. The last three patients admissions were identified as scheduled patients and two arrived at 1850 hours and the last at 2120 hours.