HospitalInspections.org

Based on interview and record review, the facility failed to accept an appropriate inbound transfer from an outside hospital emergency department (ED) of 1 of 24 sampled patients (Patient 6), for whom the facility had both specialized capabilities and current capacity. Refer to A-2411. The facility failed to provide a medical screening examination (MSE) to 1 of 24 sampled patients (Patient 20). Refer to A-2406. The facility failed to document physician certifications enumerating and weighing risks and benefits of hospital transfers for 6 of 24 sampled patients (Patients 1, 9, 10, 17, and 19). Refer to A-2409.

The deficient practices had the potential to delay treatment of patients with emergency medical conditions requiring hospital transfers, cause emergency medical conditions to go unrecognized and untreated, and limit patients' right to be fully informed regarding the risks and benefits of hospital transfers.

Based on observation, record review, and interview, the hospital failed to post Emergency Medical Treatment and Active Labor Act (EMTALA - the law requiring treatment of all patients requesting care at Emergency Departments- ED) signage in languages understandable by patients seen at the Seton Coastside ED, in 4 out 4 areas hospitals were required to post signs, the entrance, admitting area, waiting room and treatment areas. At the Seton Daly City ED, the EMTALA postings at the ED registration desk did not include postings in Tagalog, and the contact information for the state agency was incorrect.

The deficient practices had the potential to discourage patients who did not understand the language posted on the signs from seeking treatment at the ED, delaying care needed to treat emergent conditions.

Findings:

1. During an observation on 6/15/21, at 12:30 p. m, the hospital posted EMTALA signs at the Seton Coastside ED entrance, admitting area, waiting room, and patient treatment area, Room 1, Room 2, and Room 4 in English language.

During an interview with Staff Nurse (SN) 2 on 6/15/21, at 12:45 p.m., SN 2 acknowledged that the hospital posted EMTALA signs at the ED entrance, admitting area, waiting room, and patient treatment rooms in English language only. He stated that patients that were seen for treatment at the ED spoke "predominantly English and Spanish languages."

During a review of the hospital policy and procedure titled "EMTALA MEDICAL TREATMENT & ACTIVE LABOR ACT (EMTALA-the law requiring treatment of all patients requesting care at ED), COMPLIANCE WITH" revised 7/20, the policy and procedure indicated that the hospital did not address the requirement for hospitals to post EMTALA signs in languages understandable to patients seen at the ED.




26674

2. In an observation and interview on 6/15/21 at 10:39 a.m., the EMTALA postings adjacent to the Seton Daly City ED registration desk included postings in English, Spanish, and Chinese, but no postings in Tagalog. The postings indicated patients with complaints could contact California Department of Public Health (CDPH) at a previously used address and phone number in Daly City. Administrative Staff 4 (AD 4) acknowledged the postings were in English, Spanish, and Chinese, contained CDPH contact information in Daly City, and offered to change the CDPH contact information to the current address and phone number in Brisbane. AD 4 stated the hospital saw a lot of patients who only speak Tagalog. The EMTALA postings in Treatment Room 4 of the ED contained contact information for CDPH in Brisbane; AD 4 acknowledged that the signs in Treatment Room 4 contained different contact information than the signs at the registration desk.

A surveyor attempt to call the two telephone numbers on the EMTALA posting adjacent to the Daly City ED registration desk indicated the number beginning with area code 650 connected to the City of Daly City rather than CDPH. The number beginning with area code 800 did connect to CDPH.

Review of the listing of CDPH Regional Offices (https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/DistrictOffices.aspx, accessed 7/5/21) indicated the San Francisco Regional Office was responsible for facilities in San Mateo County, and was located at 150 North Hill Drive, Suite 22, Brisbane, California 94005. The phone number for the San Francisco Regional Office was listed as (415) 330-6353 or (800) 554-0353.

Based on record reviews, the hospital failed to maintain a central log (complete list) on all patients who sought treatment at the emergency department (ED) that included documentation whether patients were treated and admitted to the hospital, discharged home or transferred to other hospitals, for 3 out of 3 un-sampled patients, Patient 25, 26, and 27.

This failure had a potential to jeopardize patients health due to the hospital's inability to track patients' treatment of medical conditions, contributing to patients adverse events (unanticipated health care injuries), and compromising their health and safety.

Findings:

During a review of the hospital document "titled ER Log.xlsx", undated, the ER Log indicated that the hospital did not document the date, time, and whether Patient 25, 26, and 27 were admitted, discharged home or transferred to another hospital following treatment at the hospital.

During a review of the hospital's policy and procedure titled "Emergency Medical Treatment & Active Labor Act, Compliance with" dated 7/20, the policy and procedure indicated that the hospital required staff to:
1. Record whether patients seen at the ED were admitted and treated, stabilized and transferred to another hospital or discharged home.
2. Establish a policy and procedure for maintaining timely recordings of log entries.

Based on interview and record review, the facility failed to provide a medical screening examination (MSE) to 1 of 24 sampled patients (Patient 20). The deficient practice had the potential to cause emergency medical conditions to go unrecognized and untreated.

Findings:

Review of Patient 20's medical record indicated he arrived at the facility on 2/12/21 at 10:33 p.m., but was not seen by a triage nurse until 29 minutes later at 11:02 p.m., at which time Patient 20 was triaged by Staff Nurse 5 (SN 5). At that time, Patient 20 complained of feeling suicidal and stated his medications had been stolen. Patient 20 was assigned triage level "4 - Semi-Urgent" and returned to the waiting room. A "Miscellaneous Nursing Note" dated 2/13/21 at 12:09 a.m. indicated Patient 20 was "smashing and destroying hospital property". A "Miscellaneous Nursing Note" dated 2/13/21 at 12:18 a.m. indicated, "hospital security called daly city [sic] PD [police department]... escorted out by police, triage [sic] room door glass window smashed broken, smashed with his belongings in plastic bag( looks and smells like homeless person, appears to by [sic] homeless)". No MSE was present in the medical record.

In an interview on 6/17/21 at 2:59 p.m., the clinical informatics staff member stated she did not see anything documented by a physician in Patient 20's medical record for the visit from 2/12/21 to 2/13/21.

In an interview and record review on 6/18/21 at 3:19 p.m., SN 5 stated his shift started at 11:30 p.m. on 2/12/21 and he must have triaged Patient 20 when he (SN 5) arrived for his shift. SN 5 stated hospital security called Daly City police regarding Patient 20 and the nursing supervisor came to the emergency department waiting room. SN 5 stated he did not know what happened, but Patient 20 was escorted out. Review of the staffing schedule titled, "EMERGENCY ROOM DATE: 02/12/21 FRIDAY" indicated SN 5 had worked both the evening shift and night shift on 2/12/21. SN 5 then stated he had worked 3:30 p.m. to 8:00 a.m., there was no triage nurse assigned, "the charge nurse asks whoever is free to do triage, and probably what happened is the charge nurse asked" him (SN 5) to triage Patient 20.

Based on record review, and interview, the hospital failed to ensure staff certified (documented specifics) that patients' medical benefits of medical treatment at receiving hospitals outweighed the risks associated with transfer to those hospital, for 5 of 24 sampled patients' medical records for which patients had not requested transfers, Patient 1, 9, 10, and 19.

For Patient 1, 10, and 19, the hospital failed to ensure medical records contained documentation that benefits outweigh the risks of transfer to receiving hospitals for treatment, and whether Patient 1, 10, and 19 requested the transfer to receiving hospitals for treatment.

For Patient 9, the hospital failed to ensure medical records contained documentation of specific risks that could result from transfer to receiving hospital for treatment, and whether Patient 9 requested the transfer or the hospital offered Patient 9 transfer to receiving hospital for treatment.

For an additional 1 of 24 sampled patients (Patient 17), the hospital failed to document specific risks of transferring to another facility, failed to document a physician certification that the benefits of transfer outweighed the risks, and had contradictory documentation regarding whether or not the patient's responsible party had requested the transfer.

This failure had a potential to deprive patients of information necessary to make informed decisions about their treatment, with potential for patients to make wrong decisions for wrong treatments, contributing to adverse events (unanticipated health care injuries) and compromising their health and safety.

Findings:

1. During a review of Patient 1's "ED - (emergency department) Note" dated 04/01/21, the ED Note indicated that Patient 1 was seen at the hospital's ED for taking 10 Paxil 20 milligrams (mg) pills (used to treat anxiety) in an attempt to commit suicide. The note indicated that Patient 1 was "On Paxil since Aug 2020, prescribed for anxiety, but became depressed about 2 mo (months) ago, and has been considering suicide for a while. Patient no longer suicidal but feels anxious and sad." The note indicated that Patient 1's laboratory results included tests for "Hb (hemoglobin - measure oxygen in the blood) 14.7 (normal), Hct (hematocrit - measures amount of red blood cells) 43 (normal), Na (sodium - balances water in body tissues) 139 (normal), K (potassium - helps in moving nutrients and body waste material through the cells) 3.4 (normal), glu (blood sugar) 97 (normal). The physician documented, "ED course: Poison Control Contacted, recommend tox (toxicology - poison) screen, ASA (Acetylsalicylic Acid - aspirin) and Tylenol levels, no Charcoal (used to treat poisoning), observation for 6 hours." The note indicated that the ED physician discussed the case with ACH 1's physician "who agreed to accept patient in transfer; drug levels deferred until arrival at transfer destination 911 transport requested."

Review of Patient 1's ED Note indicated that the ED Note did not have physician's documentation of Patient 1's specific medical benefits of treatment at ACH 1, and risks associated with transferring Patient 1 to ACH 1 for treatment or whether Patient 1 requested the transfer to ACH 1.

During a review of Patient 1's "PATIENT TRANSFER: PHYSICIAN ASSESSMENT & CERTIFICATION" form, the form indicated that Patient 1 was transferred to ACH 1 at 23: 00 hours. The ED Physician documented that the reason for transferring Patient 1 to ACH 1 was, "higher level of care" and "benefits outweigh risks" of transferring Patient 1 to ACH 1 for treatment. The physician documented "benefits outweigh risks" on the area marked "D: RISK OF TRANSFER," and did not document specific risks associated with transferring Patient 1 to ACH1 for treatment.

During an interview with Informatics Representative (ITR) 1, on 6/17/21, at 10:20 a. m., ITR 1 acknowledged that Patient 1's documents, the ED Note and PATIENT TRANSFER: PHYSICIAN ASSESSMENT & CERTIFICATION, indicated that the physician did not document Patient 1's specific medical benefits of treatment at ACH 1, and the risk associated with transferring Patient 1 to ACH 1 for treatment.

2. During a review of Patient 9's document titled "ED Provider Note" dated 4/27/21, the ED Provider Note indicated that Patient 9 was seen at the hospital ED for evaluation of right lower quadrant (abdomen) pain associated with vomiting. The note indicated that the physician documented, "30 years old female with sudden onset of right lower quadrant pain. Initial concern was ruptured (torn) ovarian cyst (full of fluid), but she states she never had issues with cysts before. Bedside ultrasound (x-ray examination used to check contents of cysts) does not reveal any free fluid. Will check labs inflammatory markers (blood tests for inflammation) and CT (computed tomography - x-ray examination used to take pictures of organs being examined), if necessary." Patient 9"s pain was initially resolved with "her 1st dose of morphine (medication for pain) but patient had repeat episode of severe pain. Will give more morphine, anti-emetics (medication to treat vomiting) and await CT results. At 450 CT shows 7x6x6 cm (centimeters) ovarian cyst on the right side. Will order stat (immediate) pelvic ultrasound to rule out torsion (twisted)." The note indicated that the ED physician contacted ACH 4 "for transfer for evaluation by Gynecology for suspected ovarian torsion. They advised that they do not have any beds available for transfer." The note indicated that ED physician contacted another hospital, ACH 3 to transfer Patient 9 to ACH 3. At 06:00 a. m, the ED physician documented that Patient 3's diagnosis was "right ovarian cyst. Patient pending possible transfer for concern for intermittent right ovarian torsion with CT revealing large adnexal lesion measuring 7.0x 6.0x6.4." At 6:20 a. m., the ED physician spoke to ACH3's "OB-GYN (obstetrics-gynecology)" physician and "they will accept her for transfer ... Patient amenable to transfer so will arrange for pt (patient) to be transferred" to ACH3 for treatment.

Patient 9's ED Note indicated that the physician did not document risks associated with transferring Patient 9 to ACH 3 for treatment.

During a review of Patient 9's form titled "PATIENT TRANSFER: PHYSICIAN ASSESSMENT & CERTIFICATION" the form indicated that the hospital transferred Patient 9 to ACH 3 for treatment at 08:45 hours. The ED Physician documented that the reason for transferring Patient 9 to ACH 3 for treatment was, "ovarian torsion, need for gynecology." The physician did not document the risks of transferring Patient 9 to ACH3 for treatment. The area on the form marked "D: RISK OF TRANSFER," was left blank.

During a review of Patient 9's document titled "PATIENT TRANSFER: ACKNOWLEDGEMENT/REQUEST/REFUSAL TO TRANSFER" form dated 4/27/21, the form indicated Patient 9 did not sign the form acknowledging transfer offered by the hospital. The medical record did not contain documentation indicating that Patient 9 requested the transfer to ACH3 for treatment.

During an interview with ITR 1, on 6/17/21, at 3:20 p. m., ITR 1 acknowledged that Patient 9's documents:
i. The ED Note and PATIENT TRANSFER: PHYSICIAN ASSESSMENT & CERTIFICATION form indicated that the physician did not describe Patient 9's risk associated with transferring Patient 9 to ACH 3 for treatment.
ii. The PATIENT TRANSFER: ACKNOWLEDGEMENT/REQUEST/REFUSAL TO TRANSFER form did not contain Patient 9's signature, and the medical record did not contain documentation that Patient 9 requested the transfer to ACH 3 for treatment.

3. During a review of Patient 10's "ED Provider Note" dated 1/15/21, the ED Provider Note indicated that Patient 10 was seen at the hospital ED for AMS (acute mental status change). The note indicated, "66-year-old female with hx (history) DM (Diabetes Mellitus) Type 2, CAD (coronary artery disease - clogged heart arteries), CABG (Coronary Artery Bypass Graft - surgery to unclog heart arteries) 9/30/2020, on Pacemaker and Plavix (medication used to thin blood) BIBA (brought in by ambulance) presenting with sudden onset of AMS and right sided weakness starting at 1435 today while at home with family." The ED physician documented "Will order code stroke, stat head CT. Will plan to give TPA (Tissue Plasminogen Activator - medication to decrease blood clots) if no ICH (intracranial hemorrhage - bleeding in the brain.)" The note indicated that the physician ordered, "Alteplase (TPA) 100 mL/hr (milliliters/hour)" IV (intravenously), and bolus (push) IVx50mL/hr IV" The physician documentation indicated, "There was no absolute contraindications to TPA identified. The telestroke neurologist (distant brain specialist) has evaluated the patient and was agreeable with plan for TPA. After the discussion with the tele-neurologist, the decision was made to administer TPA. Time TPA was initiated 1535." The note indicated that the ED physician discussed the case with "stroke neuro-interventionalist (stroke specialist)" who accepted that Patient 10 be transferred to ACH 2 for treatment. "The patient and/or family were informed of the treatment and transfer plan."

Patient 10's "ED Provider Note" did not have documentation that the ED physician described that Patient 10's benefits of medical treatment at ACH 2 outweighed the risks associated with transferring Patient 10 to ACH 2 for treatment.

During a review of Patient 10's "PATIENT TRANSFER: PHYSICIAN ASSESSMENT & CERTIFICATION" dated 1/14/21, the hospital transferred Patient 19 to ACH 2 for treatment at 1700 hours. The physician certification did not contain documentation that the ED physician documented the risks of transferring Patient 10 to ACH 2 for treatment. The area of the document marked, "D: Risks of Transfer" was left blank."

During a review of Patient 10's "PATIENT TRANSFER: ACKNOWLEDGEMENT/REQUEST/REFUSAL TO TRANSFER," form dated 1/14/21, the transfer form did not have documentation that Patient 10 or family representative requested the transfer to ACH 2 for treatment. The area of the form marked, "PATIENT REQUEST FOR TRANSFER OR DISCHARGE," was left blank. The transfer form indicated that the hospital checked the area of the form marked "PATIENT TRANSFER ACKNOWLEDGEMENT" and documented "PATIENT UNABLE TO SIGN" where Patient 10 or family representative was required to sign the form. There was no witness signature on the transfer form.

During an interview with on 6/17/21, at 13:15 p.m., with ITR 1, ITR 1 acknowledged that Patient 10's:
i. ED Provider Note did not have documentation that the ED physician described Patient 10's benefits and risks of transferring Patient 10 to ACH 2 for treatment.
ii. PATIENT TRANSFER: PHYSICIAN ASSESSMENT & CERTIFICATION did not have documentation that the physician documented the risks associated with transferring Patient 10 to ACH 2 for treatment.
iii. PATIENT TRANSFER: ACKNOWLEDGEMENT/REQUEST/REFUSAL TO TRANSFER form did not have Patient 10 or family representative signature acknowledging transfer to ACH 2, and did not have a witness signature.

4. During a review of Patient 19's "ED Provider Note" dated 2/14/21, the ED Provider Note indicated that Patient 19 was seen at the hospital ED for Tylenol Ingestion (ate Tylenol medication). Documentation on the ED note indicated that, "Patient is a 3-year-old male who was brought in by mother for possible Tylenol overdose. Per mother, grandmother found the patient with 14 opened packets of Tylenol powder, each containing 500 mg (milligram), at 0800 this morning. There was powder found on patient's face. There was no powder noted spilled around the room. Patient has not complained of any pain or discomfort. Mother states that patient has been behaving normally." At 10:20 a. m., the ED physician consulted with a pediatric intensivist (children's specialist) at ACH 4 to discuss the case and the ACH 4 pediatric intensivist "accepted patient for transfer." The ED physician documented, "The patient remained stable throughout the ED course ... The patient will be received directly" at ACH 4 "for serum acetaminophen level measurements Blood tests) and treatment"

The ED note did not have documentation that the physician described the benefits and risks of transferring Patient 19 to ACH4 for treatment.

During a review of Patient 19's "PATIENT TRANSFER: PHYSICIAN ASSESSMENT & CERTIFICATION" form dated 2/14/21, the form indicated that the hospital transferred Patient 19 to ACH 4 for treatment at 11:20 a. m. The physician certification form did not have documentation that the physician described the benefits and risks of transferring Patient 19 to ACH 4 for treatment. The area of the form marked "C: Benefits of transfer, D Risks of Transfer," were left blank.
During an interview on 6/17/21, at 2:05 p. m., with ITR 1, ITR 1 acknowledged that Patient 19's:
i. ED Provider Note did not have documentation that the physician described the benefits and risks of transferring Patient 19 to ACH 4 for treatment.
ii. PATIENT TRANSFER: PHYSICIAN ASSESSMENT & CERTIFICATION form did not have documentation that the physician described benefits and risks of transferring Patient 19 to ACH 4 for treatment.
iii. The area of the form marked "C: Benefits of Transfer. D: Risks of Transfer," was left blank.


During a review of the hospital policy and procedure titled "EMTALA MEDICAL TREATMENT & ACTIVE LABOR ACT (EMTALA-the law requiring treatment of all patients requesting care at ED), COMPLIANCE WITH" revised 7/20, the policy and procedure indicated that the hospital did not address how it required staff to document summaries of benefits of transferring patients to other hospital, and risks that could result from transferring patient to other hospital for treatment, in the medical records.



26674

5. Review of Patient 17's medical record indicated Patient 17 (a minor) arrived at the ED on 6/8/21 at 10:40 p.m., and was transferred to another hospital (acute care hospital 4, ACH 4) on 6/9/21 at 3:22 a.m. The ED physician's note dated 6/9/21 at 1:41 a.m. indicated the ED physician had discussed Patient 17 with a pediatric orthopedic surgeon at ACH 4 who had recommended the patient be transferred to ACH 4, and that transfer to ACH 4 would be Patient 17's disposition. No indication was present in the ED physician's note that Patient 17 or his family had initiated the transfer. No discussion was present in the ED physician's note regarding risks of transfer to another hospital or whether the benefits outweighed the risks. A "Miscellaneous Nursing Note" dated 6/9/21 at 1:24 a.m. indicated orthopedics at ACH 4 was contacted on 6/9/21 at 1:13 a.m. Patient 17's "PATIENT TRANSFER: PHYSICIAN ASSESSMENT & CERTIFICATION" dated 6/8/21 indicated spaces on the form marked "Reason for Transfer", "Benefits of Transfer", and "Risks of Transfer" were all left blank; the space labeled "MD Signature" was also blank. A "PATIENT TRANSFER: ACKNOWLEDGEMENT / REQUEST / REFUSAL TO TRANSFER" dated 6/9/21 at 2:32 a.m. (after the ED physician had decided to transfer the patient) indicated Patient 17's "ELDER BROTHER FOR MOTHER" was simultaneously acknowledging being informed of the hospital's reasons for initiating transfer to another hospital, initiating his own request for hospital transfer and releasing the hospital from responsibility, and refusing hospital transfer.

In an interview on 6/17/21 at 11:14 a.m., the clinical informatics staff member (CISM) acknowledged the risks, benefits, and signature were all blank on Patient 17's physician certification regarding the hospital transfer. The CISM acknowledged she could not find a discussion of risks and benefits of hospital transfer elsewhere in Patient 17's medical record. In an interview on 6/17/21 at 1:22 p.m., the CISM acknowledged Patient 17's "PATIENT TRANSFER: ACKNOWLEDGEMENT / REQUEST / REFUSAL TO TRANSFER" appeared to both be requesting and refusing a hospital transfer.

Based on interview and record review, the facility failed to accept an appropriate inbound transfer from an outside hospital emergency department (ED) of 1 of 24 sampled patients (Patient 6), for whom the facility had both specialized capabilities and current capacity. The deficient practice had the potential to delay treatment of patients with emergency medical conditions requiring hospital transfers.

Findings:

Review of a letter from the Administrative Director of Regulatory, Licensing and Quality Management (ADRLQ) at Acute Care Hospital 4 (ACH 4) to Centers for Medicare & Medicaid Services dated 4/8/21 regarding Patient 6 indicated, "On 3/15/21, Seton Medical Center [Seton] was contacted for transfer. That same day, Seton declined to accept the patient transfer because they do not accept this patient's insurance." The letter indicated Patient 6 was in the ED at ACH 4 at the time of the attempted transfer.

In a telephone interview on 4/22/21 at 4:17 p.m. with the California Department of Public Health (CDPH) Health Facilities Evaluator Supervisor (HFES), the Associate Chief Nursing Officer for Capacity and Access (ACNO) at ACH 4 stated ACH 4 had faxed a transfer request regarding Patient 6 to Seton Medical Center (Seton) on 3/15/21 at 11:00 a.m.. The ACNO at ACH 4 played a telephone recording to the HFES which the ACNO stated had been made on 3/15/21 at 11:40 a.m., and which the ACNO stated was regarding Patient 6. The recording indicated, " ... [first name of Seton Intake Coordinator] calling from Seton Geri[atric] Psych[iatry]. It looks like insurance, we do not accept that insurance as their primary."

Review of a transcript of the telephone recording provided by the ADRLQ at ACH 4 on 7/1/21 indicated the Seton Intake Coordinator had difficulty pronouncing Patient 6's name, but ACH 4 staff (identified by first name only) concluded the call was regarding Patient 6. The transcript indicated the Seton intake coordinator stated, "I got a referral package... we do not accept that insurance as a primary..."

Review of an e-mail from the ADRLQ at ACH 4 to the HFES dated 4/21/21 at 2:28 p.m. indicated, "Enclosed please find the packet that was sent to Seton. This is what we have as documentation." A file attached to the e-mail titled "TransferPacket sent to Seton.pdf" included a fax cover sheet dated 3/15/21 at an unspecified time from the ACH 4 transfer center to unspecified recipients. The cover sheet did not include a patient name but indicated, "PATIENT IN [ACH 4] ER [emergency room] WE HAVE NO BEDS". Attachments to the cover sheet included 31 pages of documents regarding Patient 6 with dates ranging from 3/14/21 at 12:00 p.m. to 3/15/21 at 3:30 p.m.

In an interview on 7/1/21 at 3:01 p.m., the ACNO at ACH 4 stated the first seven pages of the e-mailed transfer packet had been sent to Seton, and the remaining pages were printouts from Patient 6's medical record provided as background to ACH 4's report of a suspected violation which had not been sent to Seton. The ACNO stated the time stamps indicating 3/14/21 at 1:01 p.m. on pages two through seven of the transfer packet were when the ACH 4 ED faxed the documents to the ACH 4 transfer center. The ACNO stated he knew the first seven pages had been faxed to Seton on 3/15/21 right before 11:00 a.m. because he had talked to the transfer center team and had some documentation.

Review of a "Timeline of completed request for [Patient 6]" (printed 3/16/21) provided on 7/1/21 by the ADRLQ at ACH 4 indicated Seton Medical Center was considered as a transfer destination on 3/15/21 at 10:59 a.m. The timeline indicated on 3/15/21 at 11:40 a.m., "Seton called to advise that they do not accept this patient's insurance", and "Declined SETON MEDICAL CENTER as Transfer Destination Reason: Out of Network".

Review of the first seven pages of the transfer packet e-mailed by ACH 4 indicated Patient 6 was 64 years old, had bipolar disorder (a mental health condition that causes extreme mood swings including emotional highs and lows) and was detained involuntarily due to, "Having suicidal thoughts... Cannot provide plan for food/shelter/clothing." Review of the remaining 24 pages of medical records included in the transfer packet indicated that Patient 6 was tachycardic (had a high heart rate) on arrival to the emergency department, but the tachycardia had resolved by 8:00 a.m. on 3/15/21. The ED attending physician's note dated 3/14/21 at 1:01 a.m. indicated, "At this time there is no evidence of non-behavioral medical emergency that would preclude transfer of care to the psychiatric service (or another facility) for further psychiatric as well as medical evaluation." An "ED Provider Notes Addendum" signed on 3/14/21 at 10:36 p.m. indicated, "Now she is medically cleared for psych[iatry]."

Comparison of the transfer packet to Seton's policy "ADMISSIONS, TRANSFERS AND DISCHARGES" for the Geriatric Behavioral Health Unit (revised 6/2018) indicated Patient 6 met Seton's criteria for admission to the unit. Patient 6 was over 55 years old. Patient 6's medical record indicated she required involuntary psychiatric admission, was a danger to herself, was unable to provide for food, clothing, or shelter. Patient 6's medical record indicated at the time Seton was contacted for transfer, she did not have head trauma, organ failure, an unstable cardiac condition, unresponsiveness, advanced dementia, or an infectious process requiring isolation, and did not require medical treatments, blood administration, cardiac monitoring, or isolation.

In an interview on 6/15/21 at 9:43 a.m., Administrative Staff 2 stated the geriatric behavioral health unit received direct admissions consisting of referrals from 27 counties, the majority of which were in ED's at other hospitals. Staff Nurse 1 (SN 1) stated referrals were kept for one month, then shredded; patients who were admitted had a medical record. SN 1 stated the facility had no records regarding Patient 6. Administrative Staff 3 (AD 3) stated the facility only knew the information regarding Patient 6 which had been provided by the CDPH HFES, the facility did not accept patients who were clinically inappropriate, and the facility had taken Patient 6's insurance in the past. AD 3 stated if the facility was out of network and did not have a contract with a patient's insurance carrier, the facility was required to explain the billing implications and obtain the patient's consent prior to transfer, and that such patients never give consent.

In an interview on 6/15/21 at 2:03 p.m., the Intake Coordinator stated she could not recall Patient 6. She stated transfer requests were logged, and the faxed requests were kept for one month. She stated the facility accepted all insurance and she could not recall what she said regarding Patient 6, but normally she explained if a health plan was not contracted with the facility, the facility and the health plan could execute a contract or the patient could pay.

Review of a spreadsheet titled "SETON GERIATRIC BEHAVIORAL HEALTH UNIT MONTH: March" indicated the document logged referrals received by the unit from other hospitals and their disposition. The log indicated a patient with the same initials as Patient 6 was referred from ACH 4 on 3/15/21, was reviewed by the intake coordinator and Provider 2, and and was not admitted to Seton. The log did not indicate why Patient 6 was declined. The log indicated two other patients referred by outside hospitals were admitted to the geriatric behavioral health unit on 3/15/21.

In an interview on 6/16/21 at 1:39 p.m., AD 3 stated the minimum age for the geriatric behavioral health unit was changed to 55 in June, 2018. AD 3 stated she did not have knowledge of the clinical reason Patient 6 was declined, but she had spoken with Provider 2, who had stated insurance was not the issue, though he could not remember Patient 6.

In an interview and record review on 6/16/21 at 2:23 p.m., AD 3 stated the geriatric behavioral health unit had a maximum census of twenty patients, and the staffing ratio was one to six [one nurse for every six patients], plus break relief if the unit is full. AD 3 stated for example, if the unit had more than 12 patients, it would need three nurses to meet staffing ratios, plus a fourth nurse to provide break relief. Review of the "Seton Medical Center Geriatric Behavioral Health Unit DAILY CENSUS REPORT" for 3/15/21 indicated the AM shift on 3/15/21 had 16 patients and 5 nurses; surveyor calculation indicated five nurses at a staffing ratio of 1 to 6 would be sufficient for more than twenty patients, even if one nurse was dedicated to break relief. AD 3 stated there were other considerations beyond the census, for example if a patient required one to one nursing. AD 3 stated she did not remember whether the unit was open to new admissions on 3/15/21 or not. AD 3 stated the unit's capacity was twenty patients, eighteen if someone required one to one nursing. AD 3 stated sixteen patients was not the unit's normal stopping point, but she couldn't say for sure and would check with the staffing office.

In an interview and record review on 6/17/21 at 9:24 a.m., AD 3 stated she had retrieved the staffing notes for the treatment team on 3/15/21 and "found the acuity was high for us." AD 3 stated two patients needed observations every five minutes, one needed to be in line of sight, one patient needed one to one nursing, 13 patients were high fall risk, there were two discharges and two admissions. Review of the "Seton Medical Center Geriatric Behavioral Health Unit PATIENT ACUITY" dated 3/15/21 at 7:30 a.m., as well as the "Seton Medical Center Geriatric Behavioral Health Unit DAILY CENSUS REPORT" dated 3/15/21 confirmed AD 3's statements. Review of the "Seton Medical Center Geriatric Behavioral Health Unit Staff Assignment" dated 3/15/21 indicated on the AM shift, there were a total of five nurses, one assigned break relief, one assigned to the patient requiring one to one nursing, and three nurses with five patients each. Two of the nurses assigned five patients had one patient each requiring observations every five minutes, one nurse assigned five patients had one patient who needed to be kept in line of sight. AD 3 stated she could not definitively say Patient 6 was declined because of the acuity. AD 3 stated the unit tried not to have more than two admissions, and in practice it was "not unusual to say there's a lot going on, we might want to cap." AD 3 stated there was no way to know if that was done on 3/15/21, the unit did not keep track when it was capped to new admissions, and "we try not to cap." AD 3 stated the maximum number of admissions the unit had taken on one day was four; SN 1 stated the maximum was three admissions. SN 1 stated the unit's staffing was "OK unless someone calls in sick." SN 1 started there was a sufficient pool of staff for twenty patients, and the hospital had per diem nurses it could call. SN 1 stated if nobody responded to a call to pick up an extra shift, the hospital would first offer time and a half premium pay, then double time premium pay. SN 1 stated, "On March 15th, I don't believe we were short of staff." SN 1 stated on the day shift of 3/15/21, the unit had "all RNs [registered nurses] plus break [a nurse assigned to cover breaks], plus one doing one to one. The staffing was OK, but we can't [sic] accommodate more." When the surveyor asked whether the hospital had requested additional staff to pick up shifts, SN 1 replied, "Maybe we sent out the call, maybe not. I will check with the staffing office."

In an interview and record review on 6/17/21 at 12:54 p.m., SN 1 stated, "The 3/15 schedule shows a sick call. We did not send out a call for an additional nurse. We had five RNs on the schedule... One was for one to one, three were for patient care, one was for break relief." SN 1 provided a document titled "GERO [geriatric] DATE: MONDAY 3/15/2021". The document indicated for the day shift, the census was sixteen patients, six nurses had been scheduled, but one called in sick on "3/14 @ 1514". No documentation was present indicating that the hospital had attempted to contact staff to pick up a shift.

In an interview on 6/17/21 at 1:03 p.m., Provider 2 stated Patient 6's referral was three months ago, the patient did not sound familiar, the surveyor's summary of Patient 6 was not exceptional, and he did not keep a record of the patients he reviewed. Provider 2 stated patients were presented to him over the phone, usually by the charge nurse. Provider 2 stated if it sounded like a patient was in need of inpatient services, then the patient was accepted unless there was a medical reason not to. Provider 2 stated insurance was not a factor in the decision and is never brought up.