HospitalInspections.org

Based on review of medical records, staff interviews, medical staff rules/regulations, and policies/procedures, it was determined the hospital failed to comply with 489.24, as evidenced by failing to:

489.24(d)(1-3) Tag A2407

a) provide stabilizing treatment for Pt #13 prior to sending the patient home from the Assessment and Referral Department to wait for an available bed for suicidal ideation, for which the hospital recommended inpatient treatment; and

489.24(d)(1)-(2) Tag A2409

a) contact the receiving hospital to ensure they have space and qualified personnel to treat the patients; accept the transfer; and send pertinent medical records for 2 of 5 transferred patients (Pt #'s 11 and 17).

These deficient practices resulted in the hospital's failure to be in compliance with the Special responsibilities of Medicare hospitals in emergency cases (EMTALA requirements).

Based on review of medical records, medical staff rules and regulations, it was determined that the hospital failed to provide stabilizing treatment for 1 of 1 patient (Pt #13) prior to sending the patient home from the Assessment and Referral Department to wait for an available bed for suicidal ideations (SI), in which the hospital recommended inpatient treatment.

Findings include:

The hospital's Medical Staff Rules and Regulations dated 03/10/10, required: "...Qualified Medical Personnel...provide ongoing assessment and stabilization within the capacity of a Level I facility...Emergency Medical Condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including...psychiatric disturbances...) such that the absence of immediate medical attention could reasonably be expected to result in:...Individuals expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or others...."

Patient #13, an adolescent, arrived on 01/30/13 at 2000, with SI and a plan. The following information was documented by the clinician (Employee #21) conducting the medical screening exam: "...presents w/a depressed mood, flat affect...Pt reports 'if I go home I will OD'...pt is in need of an acute placement at this time. Pt is recc (recommended) for inpt Tx, however ABH does not have any beds to accommadate (sic) the Pt as this time. Contacted (name of hospital #4) and (name of hospital #3), no F (female) adolescent beds...Staffed with Dr. (Physician #3) who suggested that parents should take Pt home until later today 1/30 when a bed will be avail. (sic) for the pt. Parents will bring child back at 1330 on 1/30 to be admitted for inpt Tx...Parents are agreeable stating they will monitor the pt throughout the remainder of the, (sic) However, Pt really needs inpt Tx...."

Nursing documented the following: "...01/30/13, 0134...called (Name of hospital #5) ER and spoke with charge nurse...Explained situation regarding pt...The ER physician told the (charge nurse) that it was not appropriate to transfer this pt to the ER just because there were no adolescent beds available in the valley...(name of Clinician evaluating Pt #13) also spoke to the nurse...She was also told they would not be able to accept this pt...TC (telephone call) Dr. (Physician #3)...He told the SW (social worker) (Employee #21) to speak to parents and allow them to take her home and return when a bed is available. Parents were also given the option to take pt to an ER if they felt unsafe taking the patient home...."

The hospital allowed Pt #13 to leave the hospital with Suicidal Ideations and a plan, accompanied by parents to return later for admission when the bed was available.

Based on review of hospital policies/procedures, patient medical records, and staff interviews, it was determined the hospital failed to: contact the receiving hospital to ensure they have space and qualified personnel to treat the patients; contact the receiving hospital and accept the transfer; and send pertinent medical records for 2 of 5 transferred patients (Pt #'s 11 and 17), as evidenced by:

1. Patient #11, an adolescent, with suicide ideation, was transferred to another acute care hospital (without psychiatric services) on 01/26/13, without contacting the receiving hospital to accept the patient and sending pertinent medical records; and

2. Patient #17, an adolescent, with suicide ideation and danger to others, was sent to another acute care hospital (without psychiatric services) on 02/01/13, without contacting the receiving hospital to accept the patient.

Findings include:

The hospital policy titled Patient Transport #PC 540.17 (effective 10/12), requires: "...The receiving facility will be provided, either by hard copies or fax...the...medical record pertinent to the patients' condition/reason for transportation...which may include: Medical screening examination, psychiatric evaluation, nursing assessment, psychosocial assessment, physician progress notes, nursing daily documentation, social service documents...lab work...nurse will explain to the patient/guardian...the risk and benefits of transportation specifically related to the patient's medical condition and the mode of transportation ordered...document the following on the transfer form...acceptance of the receiving facility as acknowledged by receiving facility staff member (name and title of acknowledging staff member, along with name of accepting doctor will be obtained/documented)...mode of transportation...Physician Certification...."

Patient #11, an adolescent, arrived on 01/26/13 at 1520 hours. The following information was documented by the clinician conducting the medical screening exam: "...presented...for SI (suicide ideation) c (with) plan to OD (overdose) on Ibuprofen. Pt. has hx (history) of feeling 'horribly depressed' and extreme agitation (thoughts of suicide and/or homicide). Pt. attempted suicide 4 years ago via OD. Recommend IP (inpatient) (Psych) to Tx (treat) SI and mood dysregulation. Writer contacted Patient Services and was advised there are no available beds at either of the ABH locations. Writer called for bed availability at (name of hospital #3) and (name of hospital #4), yet none were available...Dr (name Physician #2) who agreed with recommendation to transport to nearest ER for safety. Parents refused medical transport, however, they will transport pt to (name of hospital #2)...."

No medical health issues were identified for the patient.

A parent signed a form titled Informed Consent to Refuse which included: "...(Name of Hospital #1) and the treating provider have informed me of the benefits that might reasonably be expected from the offered services are: safe transport to the ER...receive immediate treatment en route to ER...quicker admission to ED...and the risks of refusing these services are: no coordination of care w/ER, not receive treatment until after admission into the ER...."

During an interview on 02/07/13 at 0900, with Physician #2 on call for Patient #11, she explained that a parent can refuse for the child. She recalled that the parent was refusing the mode of transportation. She explained that she does not call a receiving hospital, but the clinician evaluating the patient usually does.

During an interview on 02/07/13 at 0830, with Employee #18, the clinician evaluating Patient #11, explained the parent wanted the patient to go to the ER, but they didn't want him to go by ambulance, therefore, he had the parent sign the refusal for transfer. When asked if he called the receiving hospital, he explained he usually calls, but he couldn't be sure and there was no documentation of contacting the hospital for acceptance or if pertinent medical records were sent. He explained that patients cannot wait for beds at this hospital because there are only 3 assessment and referral rooms and they're very small. He will transfer the patient to another ER, even if they do not provide psychiatric care, because it is safer for the patient.

Employee #4, confirmed during an interview on 02/08/13 at 1200 hours, that there was no documentation of contacting the receiving hospital for acceptance of the patient or documentation if medical records were sent to the receiving hospital.

Patient #17 an adolescent, arrived on 02/01/13 at 1840, with SI and Danger to others (DTO). The following information was documented by the clinician conducting the medical screening exam: "...today Pt kicked one of his friends in the testicles which resulted in being pushed off his bike. Pt went home, retrieved a hammer from his garage and throwing the hammer at friend nearly hitting him...pt has become increasingly violent toward family. Pt has been kicking and hitting brother and mother, which is uncharacteristic...Last week, pt hit M (mother) w/ a cord and threatened to kill his younger brother...Recommend IP (Psych) Tx, DTO bxs (behaviors), SI, and mood stabilization. There is no bed availability at ABH-Tempe and recommenced to be transferred to (sister facility name in Glendale, hospital #6). Parents did not want to transport pt to Glendale location due to being 'too far west'. Parents agreed to transport pt to (name of hospital #7) for safety. Parents will wait for bed availability while at (hospital #7). Staffed case w/ Dr (Physician #5) who agreed with recommendation to transport pt to (hospital #7)...."

The Physical Health Screening form completed for the patient did not identify any medical health issues.

During an interview with Physician #5 on 02/07/13 at 0845, she explained her understanding is if the hospital does not have beds available she sends the patients to another ER to wait for a bed. Even if that hospital does not have psychiatric services or beds. When asked if patients are given the option of waiting at the hospital she said she didn't know.

During an interview on 02/07/13 at 0830 hours, with the Employee #18 evaluating Pt #17, he explained that patients cannot wait for beds at this hospital because there are only 3 assessment and referral rooms and they're very small. He will transfer the patient to another ER, even if they do not provide psychiatric care, because it is safer for the patient.

Employee #18 had the parents sign a form titled Informed Consent to Refuse which included: "...(Name of Hospital #1) and the treating provider have informed me of the benefits that might reasonably be expected from the offered services are: safe transport to the ER...receive immediate treatment en route to ER...quicker admission to ED...and the risks of refusing these services are: patient could commit suicide en route to hospital...."

Employee #18 was asked why he had the parents sign a refusal form for transfer since they were agreeable to take their son to another hospital. He explained it was because they refused the first choice (sister facility in Glendale, hospital # 6).

The medical record did not contain documentation of the sending hospital calling the receiving hospital for acceptance of the patient. Employee #4 confirmed they did not have documentation from the accepting hospital for Pt #17.