HospitalInspections.org

1. Based on review of the medicals records, ambulance trip report review, current Policy and Procedure review, EMTALA LOG review, review of Medical Staff Bylaws and Rules and Regulations of the Medical Staff, Medical Staff Roster review, EMTALA Staff training, Admissions Counselor schedules review, Intake/Admissions Counselor Job Description reviews, and Physician Credentialing and Personnel files review, and staff interviews the facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital emergency department including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists for one (#22) of twenty-five (25) sampled patients. The facility failed to ensure that an appropriate medical screening examination was provided by a Qualified Medical Personnel (QMP) as defined in the facility's Rules and Regulations of the Medical Staff for 1 (#21) of 25 sampled patients. Refer to findings in Tag A-2406.


2. Based on review of medical records, current policy and procedure review and interview, the facility failed to ensure if an individual comes to the facility's hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide within their capabilities, of staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for 2 (#21 & #22) of 25 sampled patients. Refer to findings in Tag A-2407.

3. Based on review of medical records, review of ambulance trip report, policy and procedure review, Consent for medical emergency treatment form review, review of facility quality data, Rules and Regulations for Medical Staff review, ED log reviews, and administrative staff interviews the facility failed to ensure that medical treatment was provided that was within its capacity that minimized the risks to the individuals health; failed to ensure that the receiving hospital had agreed to accept the individuals; failed to ensure that the receiving hospital had available space and qualified personnel for the treatment of the individuals; and failed to obtain written certifications for transfer for 2 (#21 ) of 25 sampled patients. Refer to findings in Tag A-2409.

4. Based on review of medical records, review of facility deflection log, policy and procedure review, bed unit census report review, ambulance trip report review; and Administrative staff interviews; Riverwoods Behavioral Health System (receiving hospital) refused to accept from referring hospitals within the boundaries of the United States appropriate transfer of individuals who required such specialized capabilities or facilities when the receiving hospital had the capacity to treat the individuals for 5 (#2, #3, #4, #5, & #6) of twenty-five ( 25) sampled patients. The hospital failed to adopt and implement a policy and procedure that addressed EMTALA Recipient Hospital Responsibilities. Refer to findings in Tag A-2411.

Based on review of the Emergency Medical Treatment and Labor Act (EMTALA) Log, staff interview, ambulance trip report, and review of facility policies, it was determined that the facility failed to ensure that a medical record was created/maintained by the facility related to individuals transferred to and from the hospital for a period of 5 years from the date of treatment for one (1) individual (#22) of twenty-five (25) sampled patients.

Findings were:

On 04/10/17, the facility's Emergency Medical Treatment and Labor Act (EMTALA) Log for 12/01/15 through 04/10/17 was reviewed. The EMTALA Log noted that on 03/26/17 at 3:45 p.m., patient #22's was a walk-in patient who arrived with a complaint of chronic depression. The log noted that the patient did not have an EMC and that the patient was transferred by ambulance to an acute care hospital for medical clearance.

On 04/11/17 at 3:30 p.m., the Director of Admissions (#7) provided an ambulance trip report for patient #22. The Director confirmed that there was no documented evidence that a medical record was created for Patient (#22) as stated in their policy. The facility failed to ensure that a medical record was created for patient #22 on 3/26/2017 when he/she presented to the hospital seeking medical evaluation and treatment.

Review of the ambulance trip report revealed the ambulance attendants were informed by Riverwoods staff that the patient (#22) had been "seen for alcohol intoxication and seeking detox". The trip report revealed the patient was transferred to a local acute care hospital.

Review of facility policies failed to reveal a policy which addressed the creation or maintenance of EMTALA records. Review of facility policy entitled Progress Record Documentation, policy # CS.005, IM.019, date issued 10/08, revealed documentation of patient care must be performed to communicate the treatment provided and its results. An interview was conducted with the Chief Executive Officer (#5-CEO) on 4/13/2017 at 11:30 a.m. The CEO confirmed that the facility was unable to locate a policy that was specific to the creation of a medical record.






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Based on review of the medicals records, ambulance trip report review, current Policy and Procedure review , EMTALA LOG review, review of Medical Staff Bylaws and Rules and Regulations of the Medical Staff, Medical Staff Roster review, EMTALA Staff training, Admissions Counselor schedules review, Intake/Admissions Counselor Job Description reviews, and Physician Credentialing and Personnel files review, and staff interviews the facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital emergency department including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists for one (#22) of twenty-five (25) sampled patients. The facility failed to ensure that an appropriate medical screening examination was provided by a Qualified Medical Personnel (QMP) as defined in the facility's Rules and Regulations of the Medical Staff for 1 (#21) of 25 sampled patients.

Findings were:

1. Policy & Procedures
Review of facility policy PC.001, Assessing An Emergency, issued 10/08, revealed that it is the facility's policy to assess, stabilize, and/or appropriately transfer individuals who present with an EMC. QMP, as designated by the Board of Governors and the Medical Executive Committee, should provide an appropriate MSE for any individual who comes to the facility and requests an examination to determine whether the person has an EMC ...CRITERIA FOR EMERGENCY
The following criteria shall be used to determine whether or not an emergency medical condition exists:
1.1 Definition of "EMC". A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:
1.1.1 Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
1.1.2 Serious impairment to bodily functions; or
1.1.3 Serious dysfunction of any bodily part or organ
1, 2 mental Health Code. With respect to individuals presenting with psychiatric disturbance or symptoms of substance abuse, the facility should use the criteria for emergency detention under the State Mental Code to determine whether such individuals have emergency medical conditions. Guidelines include the following:
1.2.1 The person evidences symptoms of mental illness or chemical dependency.
1.2.2 The person evidences a substantial risk of serious harm to self or others; such risk should be specifically documented.
1.2.3 The risk of harm should be imminent unless the person is immediately restrained.
1.2.4 There should be evidence of specific recent behaviors, overt acts, attempts or threats that should be described in specific detail.
1.2.5 An emergency detention is the least restrictive means by which the necessary restraint may be accomplished ...
2.0 Screening Examination. An appropriate MSE should be provided to the individual by QMP for determination as to whether or not an emergency medical/psychiatric condition exists. The screening examination shall not be delayed in order to inquire as to whether or not the individual has sufficient financial resources; to pay for treatment, including the availability of insurance coverage.
2.2 Emergency State. If, after a screening examination, the QMP believes that an individual appears to be in an emergent state, the individual should be referred to a physician for assessment. If a physician is not immediately available, the QMP should contact the on-call or other physician and provide a full report of the patient's clinical condition. The physician should:
2.2.1 Make the final determination as to whether an emergent medical condition exists ..."

Review of facility policy PC.004, Classification/Organization of Emergency Services, issued 10/08, revealed that the facility limits its services to the treatment of patients with substance abuse and psychiatric disorders and does not provide comprehensive emergency medical care to its patients, employees or to the public. The facility provides Level IV emergency services, offering reasonable care in determining whether an emergency exists, rendering lifesaving first aid or other treatment to stabilize the emergent condition within the capability of the facility and providing an appropriate referral/transfer as indicated to the nearest facility capable of meeting the patient's emergency treatment needs. 2.1 The on-call physician is readily available for primary coverage of emergencies

Review of facility's policy PC.105, Plan for Provision of Care, issued 10/08, revealed that the Health System is a private, freestanding healthcare facility that specializes in psychiatric and chemical dependency treatment. Inpatient psychiatric care is provided on a 24-hour basis, seven days a week with a 55-bed (facility actually has 85 beds) capacity.
5.1 Screening and Intake. The facility accepts referrals from other healthcare providers, EAP's (employee assistance programs), the professional community (physicians, community agencies, education systems, psychologist, etc.), as well as self or significant others. Intake screening and evaluations are performed by qualified assessment staff, or by a member of the clinical supervisory staff, social work staff, registered nurses, or members of the medical staff, twenty-four hours per day, seven days per week. As needed, provision for a safe transfer to an accepting facility and physician will be arranged.
7.0 Staff Qualifications and Competency. The system actively maintains ongoing processes to assure that only qualified and competent staff provides patient care, administrative or support services. An employee's competency is assessed through an internal mechanism supervised by the Human Resources Manager. Each employee performs his duties according to a criteria-based job description that reflects patient age and population specific needs and defines required qualifications and competency standards. A performance appraisal is conducted for each employee upon completion of the probationary period and at least annually thereafter. Clinical staff are also required to complete a competency assessment and orientation upon hire and annually thereafter in selected areas to assure that ongoing competency requirements are met.


Rules and Regulations of the Medical Staff
Review of the facility ' s Rules and Regulations of the Medical Staff, effective 09/24/14, revealed in section 1.11 defined Qualified Medical Persons (QMP) as those Licensed Independent Practitioners identified on Exhibit A hereto, subject to amendment from time to time by the Governing Board, as evidenced by an updated Exhibit A signed by the Chairman of the Governing Board, who are qualified within the scope of their respective licenses and in compliance with applicable State laws to perform one or more types of medical screening examinations (MSE) as contemplated by EMTALA and by the applicable rules and regulations of Centers for Medicare and Medicaid Services (CMS) implementing EMTALA, who have demonstrated current competence in performing such screenings, and who possess clinical privileges at Hospital to perform such screenings.

Section 18.0 EMTALA. All Medical Staff Members and Allied Health Professionals (AHP) Staff Members must abide by EMTALA and by all applicable rules and regulations of CMS implementing EMTALA, as reflected in Hospital EMTALA policies and procedures.
Exhibit A noted that the following are recognized as QMPs and may perform MSE: (a) Physicians; (b) Nurse Practitioners; (c) Physician Assistants; (d) Registered Nurses; and (c) Masters-level social workers and other equivalent master level clinical staff.


Medical Staff Bylaws
Review of the Medical Staff Bylaws, effective 09/24/14, revealed in section 11.4.4 (a) that the Bylaws, Rules and Regulations, Credentialing and Privileging Manual, and the procedures and forms promulgated (put into effect) in connection therewith to ensure that they reflect current practice, national standards of patient care, and an efficient organization of the Medical Staff to perform its function.


Medical Staff Roster
Review of the current Medical Staff Roster revealed the facility had the following practitioners on staff:
a.) One (1) Medical Doctor; b.) Three (3) medical Physician Assistants; c). Two (2) medical Nurse Practitioners; d) Twelve (12) Psychiatrist; and e.) Three (3) Psychiatric Nurse Practitioners


Admissions Team Roster
Review of the Admissions Team Roster revealed the facility had thirteen (13) Counselors. Eleven (11) of the Counselors were Master Prepared Counselors four (4) of these were Licensed Counselors and there were two (2) Counselors who had Bachelor Degrees in Psychology.

Admissions/Intake Job Description

Review of the Intake/Admissions Counselor Job Description revealed the education requirements were: Master's Degree in Counseling, Social Work or Psychology, or related field. License preferred.

Patient #21 Medical Record Review

The facility's Emergency Medical Treatment and Labor Act (EMTALA) Log for 12/01/15 through 04/10/17 was reviewed. The EMTALA Log revealed that on 01/14/17 at 9:30 p.m., patient #21 arrived by car. The EMTALA Log further revealed Patient #21's complaint was "psych ", the patient did not have a psychiatric EMC, and that the patient was stabilized and transferred by ambulance on 01/15/17 at 3:00 a.m.

Documentation by the employee #15 (Counselor with a Bachelor Degree in Psychology) on the facility's Comprehensive/Intake Assessment Tool revealed that patient #21 presented to the hospital on 1/14/2017 at 9:30 p.m. The patient's "Chief Complaint" was listed as "I got into a fight with my Mama." Further documentation revealed, that Patient and mother have a poor relationship, "Pt (patient) states I ...wants to kill ...self but denies a plan. Pt denies HI (homicidal ideation) ...currently tearful ...she doesn't have anywhere else to go...Pt. states she has a history of Bipolar Depression ...pt. reports 2 previous suicide attempts last attempt was December 2016. Pt cut her wrist. Pt. states ...been hearing voices telling ...to kill self. The counselor documented Patient #21 was seeking inpatient treatment. A suicide Risk Assessment tool was completed by employee #15, and the patient's overall risk level for suicide was circled as Medium 25-41.
Employee #15 also documented the patient was alert, to person, place time and situation, memory intact; judgment was poor, insight fair, and affect was flat. Continued documentation revealed the level of care determination was, "Acute Psychiatric Inpatient: 1. Behavior which is life threatened, destructive, or disabling to self or others." The patient's diagnosis was listed as Major Depressive w/psychiatric features. The patient's disposition was listed as "IP" (inpatient) and staff with (Psychiatrist name listed). The sections titled "Admitted Inpatient: Accepting Facility: TBD (to be determined) Admitting Psychiatrist: TBD Attending Psychiatrist: TBD. The patient's legal status was listed at involuntary and Employee #15 signed off as completing the assessment at 10:36 p.m. A psychiatric assessment was completed by Counselor #15 (Bachelor's Degree in Psychology), no vital signs were obtained. The facility failed to ensure that an appropriate Medical Screening Examination was conducted by a QMP (Master's level) as stated in the Rules and Regulations of the Medical staff for patient #21 on 1/14/2017.
Admissions Counselors Schedules

Review of the Admission Counselors schedules for March and April 2017 revealed a Counselor with a Bachelor ' s degree was assigned to the Admission Assessment area on the following dates:
a.) March 1, 2, 5, 6, 7, 8, 9, 12, 14, 15, 16, 19, 20, 21, 22, 26, 28, 29, and 30, 2017. This was a total of 19 out of 31 days or 61.29%.
b) April 2, 3, 4, 5, 8, 9, 10, 11, 12, 16, 17, 18, 19, 22, 23, 24, 25, 27, 29, and 30, 2017. This was a total of 20 out of 30 days or 66.67%.

Patient #22 Ambulance Trip Report

The facility's Emergency Medical Treatment and Labor Act (EMTALA) Log for 12/01/15 through 04/10/17 was reviewed. The EMTALA Log revealed that on 03/26/17 at 3:45 p.m., patient #22 was a walk-in, complaint was chronic depression, the patient did not have a psychiatric EMC, and that the patient was transferred by ambulance for medical clearance.

The ambulance report for patient #22 dated 3/26/2017 was reviewed. The ambulance trip report revealed that Patient #22 was picked up from Riverwoods Behavioral Health Hospital located at 223 Medical Center Drive, Riverdale, Georgia. The section of the Ambulance Trip Report titled "Situation" revealed in part,
"Chief Complaint: ACUTE ALCOHOL INTOXICATION ...Symptoms: Primary Symptom: Change in Responsiveness ...Providers impressions: Providers primary impression: Altered Mental Status ...Time: 3/26/2017 7:24 ... PM Provider: EMS personnel ...Circulation: ... Mental States: Alert, Oriented-Events, Oriented-Person, Oriented-Place, Oriented-Time ...Normal Gait, Normal Speech ...Skin: ...Groin Rash ... VITALS: 03/26/2017 19:24 (7:24 PM) ...BP (blood Pressure): 134/86; Pulse: 81; Resp (respiratory) Rate: 18; Sa02 100; GCS 15 ...Treatment: Time: 03/26/2017 19:24 ... Treatment given: Assessment-Adult ... Medic 11599 (EMS personnel) ...Outcome: Disposition: ...Destination Type: Hospital ... Destination Name (Another Acute Care Hospital Name and address, and city in Georgia) Patients Condition Upon Arrival at Destination: unchanged ...Disposition: Patient Disposition: Treated, Transported by EMS ...Narrative ... Responded immediate to RW (Riverwood) for transport of a 37 year old ... for transport to (Name of Acute Care Hospital) ...Upon arrival on scene at RW staff advised Patient had been seen for Alcohol Intoxication and seeking Detox. Per Intake staff Pt (patient) is going to (Name of Acute Care Hospital) for Medical Clearance. Pt is unable to go on her own due to being intoxicated ...Pt was not evaluated by Medical Staff at Riverwoods. Crew found patient in interview room. Patient walked to stretcher ...Pt. talked about wanting help for Detox." ...EMT (Emergency Medical Technician) - Paramedic, (EMT name) served as Primary Caregiver. EMT-Basic (EMT name), served as secondary patient caregiver." There was no documented evidence that a Medical Screening examination was provided for patient #22 on 3/26/2017 when he/she presented to the ED seeking medical assistance for Alcohol Detoxification. The facility failed to ensure that an appropriate medical screening examination was provided for patient #22 on 3/26/2017 as stated in the hospital's policy and procedure.

Interviews

During an interview on 04/10/17 at 10:45 a.m. in a physician ' s office, the Director of Admissions (#7) stated he/she had been at the facility since July 2016. The Director of Admissions said that he/she was not sure whether he/she had received EMTALA training. The Director of Admissions explained that the facility had thirteen (13) Admission Counselors which included himself/herself. The Director of Admissions confirmed that eleven (11) of the Admission Counselors were Master prepared Counselors and that two (2) Counselors (#15 and #16) had Bachelor of Psychology degrees. The Director of Admissions explained that after the Admission Counselor completed the Comprehensive Assessment Intake Tool the on-call physician would be contacted and the physician would determine whether the patient was to be admitted to the facility as an inpatient.

During an interview on 04/10/17 at 1:00 p.m. in the Admissions area, Admission Counselor (#9) explained that he/she had a Master ' s Degree in Social Work. He/she confirmed that the Admission Counselors performed the psychiatric MSEs and that the Director of Admissions performed evaluations on all the Admission Counselors.

During an interview on 04/12/17 at 11:45 a.m. in a physician's office, the Medical Director (#3) explained that he/she had been with the facility since 01/2016 and was mainly at the facility ' s sister location. The physician said that he/she was familiar with EMTALA regulations but had never had any formal EMTALA training. He/she explained that the Admission Counselors perform the mental health evaluations and then call the on-call physician. The Medical Director confirmed that the on-call physician made the final determination regarding whether or not to admit a patient to the facility. The Medical Director stated physician (#19) was responsible for the Riverwoods on-call schedule.
There was no documentation the medical record that the on-call physician was called when Patient #21 presented to the hospital seeking medical assistance for a medical condition.


During an interview on 04/12/17 at 2:45 p.m. in the physician ' s office, Admission Counselor (#14) explained that he/she was a Master prepared Marriage and Family Counseling. The Admission Counselor stated he/she had worked as an Admission Counselor since November 2016. The Counselor reported that he/she had received minimal EMTALA training. He/she confirmed that the Admission Counselors performed the psychiatric MSEs. The Admission Counselor explained that after the Counselor completes the psychiatric MSE the Counselor calls the on-call physician, and that the on-call physician determines whether a patient is to be admitted. The Admission Counselor stated that the Director of Admissions monitors the Counselors performance and evaluates the Counselors for competency.

During an interview on 04/12/17 at 3:10 p.m. in the physician's office, Admission Counselor (#10) explained that he/she had a Master ' s Degree in Mental Health and Community Counseling and a Licensed Associate Professional Counselor. The Admission Counselor stated he/she had worked as an Admission Counselor for five (5) years. He/she stated the Admission Counselors perform the MSE on all individuals who present to the facility requesting evaluation and treatment. He/she explained that the Director of Admissions evaluates the Counselors competency every year.

During an interview with the Chief Executive Officer (#5 - CEO) on 04/13/17 at 11:30 a.m., the CEO explained that there was no signature page for the Medical Staff Bylaws or the Rules and Regulations and that neither had been reviewed since 09/24/14.

Physician Credential and Personnel files review
Review of four (4) credential files revealed all four (4) physician's files had no documented evidence of EMTALA training.

Review of eight (8) personnel files revealed the following:
--CEO #5 had been at the facility since 03/09/17 and had not completed EMTALA training,
--DON #6 completed EMTALA training 04/28/16,
--Director of Admissions #7 completed EMTALA training 04/28/16.
--Admission Counselor #9 completed EMTALA training 06/06/16,
--Admission Counselor #10 completed EMTALA training 04/28/16,
--Admission Counselor #11 completed EMTALA training 04/28/16,
Admission Counselor #15 completed EMTALA training 04/11/16, and
--Admission Counselor #16 completed EMTALA training 11/2015.

A copy of the facility's EMTALA training revealed basic EMTALA information had to be provided to staff.

Based on review of medical records, current policy and procedure review and interview, the facility failed to ensure if an individual comes to the facility's hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide within their capabilities, of staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for 2 (#21 & #22) of 25 sampled patients.
Findings were:


Policy and Procedure:
Review of facility policy PC.001, Assessing An Emergency, issued 10/08, revealed that "it is the facility's policy to assess, stabilize, and/or appropriately transfer individuals who present with an EMC ...An individual who is determined to have an EMC should be stabilized within the fullest capability of the facility."

Review of facility policy PC.006, Medical Staff Responsibility for Emergency Patient Care, issued 10/08, revealed it was the facility ' s policy to provide for physician availability for Emergency Services consistent with the Emergency Plan for Services.
1.0 When an individual arrives at the facility with an acute psychiatric illness, the Needs Assessment Coordinator performs a brief assessment of the patient's mental status and the potential for harm or injury to self or others. (Refer to Policy and Procedure: Assessing an Emergency).
2.0 An on-call roster of physicians is maintained for emergency "walk-in" patients. Psychiatrists on the Medical Staff have privileges to provide for patient admission and treatment, including writing orders for necessary care and medication. The physician on-call is immediately contacted, is expected to respond to a pager call within fifteen (15) minutes and is expected to come as soon as possible to evaluate the patient.
3.0 If the patient meets criteria for admission and consents to admission, he/she should be admitted. In the event, a bed is not available or the patient cannot be admitted to the facility, the physician should make immediate arrangements for transfer/admission of the stabilized patient to another appropriate facility within the local area.


Medical Record Review for Patient #21
Review of patient #21 ' s medical record revealed the Comprehensive Intake Assessment Tool was completed on 01/14/17 at 10:36 p.m. by employee #15 (Counselor with a Bachelor Degree in Psychology). Employee #15 noted that the accepting facility and admitting physician were " TBD " (to be determined). There was no documentation in the medical to indicate that the on-call physician was notified that patient #21 presented to the hospital of the patients potential for harm or injury to self or others. Additionally, there was no documentation in the medical record to indicate that stabilizing treatments was provided for patient #21 on 1/14/2017.

Patient #22 Ambulance Trip Report
The ambulance report for patient #22 dated 3/26/2017 was reviewed. The ambulance trip report revealed that Patient #22 was picked up from Riverwoods Behavioral Health Hospital located at 223 Medical Center Drive, Riverdale, Georgia. Further review of the ambulance trip report revealed in part "Upon arrival on scene at RW staff advised Patient had been seen for Alcohol Intoxication and seeking Detox. Per Intake staff Pt (patient) is going to (Name of Acute Care Hospital) for Medical Clearance. Pt is unable to go on her own due to being intoxicated ...Pt was not evaluated by Medical Staff at Riverwoods."

The facility failed to ensure that stabilizing treatment was provided that was within the capabilities of staff and facilities for Patient #21 and #22, when they presented to the hospital seeking medical assistance.
Interview

On 04/11/17 at 3:30 p.m., the Director of Admissions (#7) confirmed the medical record for Patient #21 lacked documented evidence that the patient was stabilized prior to transferring the patient.

Based on review of medical records, review of ambulance trip report, policy and procedure review, Consent for medical emergency treatment form review, review of facility quality data, Rules and Regulations for Medical Staff review, ED log reviews, and administrative staff interviews the facility failed to ensure that medical treatment was provided that was within its capacity that minimized the risks to the individuals health; failed to ensure that the receiving hospital had agreed to accept the individuals; failed to ensure that the receiving hospital had available space and qualified personnel for the treatment of the individuals; and failed to obtain written certifications for transfer for 2 (#21 ) of 25 sampled patients.

Findings were:

Policy and Procedure

Review of facility policy PC.110, Patient Transfer to Another Facility, issued 10/08, revealed that the policy was to provide for transfer of patients when clinically indicated. This policy applies to patients for whom transfer is indicated after admission or stabilization following assessment and treatment of a medical or psychiatric condition.
1.1 An appropriate screening examination should be provided to the individual by Qualified Medical Personnel (QMP) to determine the treatment needs of the individual and whether an emergency medical and/or psychiatric condition exists. Assessment of an emergent medical condition should be conducted by a physician or, if none is immediately available, a registered nurse. If none available, 911 is called.
1.1.1 Appropriate treatment measures should be implemented by Qualified Medical Personnel to stabilize an emergent condition to the extent possible, including life-saving or other emergency measures in accordance with the Emergency Plan of Services and/or approved emergency medical protocol.
1.1.2 In non-emergent situations where further treatment is indicated, the physician or his/her designee should secure an accepting facility and physician prior to patient transfer.
1.2 The patient should be examined and evaluated by a physician prior to transfer. If a physician is not immediately available, the physician on-call or other available physician should be contacted by the Assessment Counselor or nursing staff and provided with a full report of the patient's clinical condition. The physician may give a telephone order for transfer without a personal examination if he/she determines that an immediate transfer of the patient is medically appropriate and that the time required to conduct a personal examination would be detrimental to the patient by unnecessarily delaying the transfer and further treatment.
1.2.1 The physician or QMP should directly communicate with the receiving facility.
1.2.2 The QMP is responsible to facilitate transfer and secure acceptance by a receiving facility, which provides treatment appropriate to the clinical condition of the patient.
1.2.3 The risks and benefits of the transfer should be explained to the patient (and/or family or guardian) by the physician or his/her designee and should be documented on the Transfer Consent/Refusal form.
1.3 The physician should determine the most appropriate mode of transport based upon the clinical condition of the patient.
1.4 Consent to transfer should be obtained.
1.5 A Memorandum of Transfer should be completed, including the certification statement that the benefits of transfer outweigh the risks, and should be signed by (i) the physician or his/her designee and (ii) an administrative representative of the facility.

Additionally, the facility provided copies of the Consent for Medical Emergency Treatment forms, and the Psychiatric/Medical Emergency Transfers quality review tool. The Psychiatric/Medical Emergency Transfers quality tool noted that the benchmark was 100%. This form evaluated transfers to ensure the following:
1. The physician's and/or QMP ' s documentation reflected the presence of an EMC.
2. Medical/psychiatric problems requiring transfer were identified.
3. Appropriate stabilizing interventions were taken to address the emergency condition prior to transfer and documented.
4. The receiving facility was notified of and accepted the transfer. (*Also, for Texas facilities, add: The receiving physician was notified of and accepted the transfer.)
5. The risks and benefits of transfer were explained.
6. Patient consent for transfer was obtained.
7. Mode of transport was appropriate.
8. A Memorandum of Transfer was completed and pertinent medical record documentation provided.


Review of facility policy PC.001, Assessing An Emergency, issued 10/08, revealed that it is the facility's policy to assess, stabilize, and/or appropriately transfer individuals who present with an EMC ...5.0 Patient Transfer- Psychiatric Condition.
5.1 Responsibility for patient transfer. The Needs Assessment Coordinator or Charge Nurse should obtain, at a minimum, a telephone consultation with the physician on-call. The physician is responsible to initiate an appropriate transfer with the receiving facility or QMP. The administrator on call is to be contacted by the Needs Assessment Coordinator or charge nurse. Following such contact, the Needs Assessment Coordinator or Charge Nurse may act as the administrative designee to facilitate transfer with the receiving facility. The Needs Assessment Coordinator or Charge Nurse is responsible for completing all required paperwork including, but not limited to, assessment, Memorandum of Transfer, and appropriate consent forms.
5.2 Individual Requests Transfer. The appropriate mode of transport for transfer should be determined by the physician.
5.3 Transfer When the Individual is Not Stabilized. While the facility is required to provide sufficient care for the individual to the extent that an emergent state no longer exists, the individual may require transfer for certain medical considerations, including, but not limited to, the following:
5.3.1 The offering facility is not capable of providing the necessary level of psychiatric care.
5.3.2 The facility is not capable of providing the required level of care because the individual has certain medical complications
5.3.3 Other specialty-type services are available in another setting.
5.4 Transfer When the Individual is Stabilized. An individual may be discharged or transferred to another facility for actual treatment of mental illness following stabilizing treatment such that an emergent condition no longer exists
Medical Staff Rules and Regulations
The facility's Rules and Regulations of the Medical Staff, effective 09/24/2014, revealed in part, "Section 17.0 Emergency Medical Care. That the decision to transfer a patient in the event of a medical emergency is the responsibility of a practitioner and a written order will be obtained. Emergency transfers shall be in accordance with the Hospital's EMTALA policies and procedures."

Emergency Department Log Review
The facility's Emergency Medical Treatment and Labor Act (EMTALA) Log for 12/01/15 through 04/10/17 was reviewed. The EMTALA Log revealed the following:
1. On 01/14/17 at 9:30 p.m., patient #21 arrived by car, complaint was " psych " , the patient did not have a psychiatric EMC, and that the patient was stabilized and transferred by ambulance on 01/15/17 at 3:00 a.m.
2. On 03/26/17 at 3:45 p.m., patient #22 was a walk-in, complaint was chronic depression, the patient did not have a psychiatric EMC, and that the patient was transferred by ambulance for medical clearance.

Medical Record Review #21
Review of patient #21's medical record revealed the Comprehensive Intake Assessment Tool was completed on 01/14/17 at 10:36 p.m. by employee #15. Employee #15 noted in the medical record that the accepting facility and admitting physician were "TBD" (to be determined). There were no transfer orders written to transfer the patient. There was no documentation in the medical record to indicate that the receiving hospital was called to ensure the receiving hospital had available space and qualified personnel to treat patient #21; and no documentation that the receiving facility had agreed to accept Patient #21. Additionally, there was no documented evidence of a transfer form, that risks and benefits were discussed, or that a copy of the medical record was sent with the patient.

Ambulance Trip Report for #22
Review of the ambulance trip report dated 3/26/2017 revealed the ambulance attendants were informed by Riverwoods staff that the patient (#22) had been "seen for alcohol intoxication and seeking detox." The trip report revealed the patient was transferred to a local acute care hospital. There was no documented evidence of a transfer form, of an accepting facility or physician, that risks and benefits were discussed, or that the receiving hospital was called to ensure the receiving hospital had available space and qualified personnel to treat Patient #22. Additionally, there were no written orders for transfer of Patient #22 on 3/26/2017.

Interviews
On 04/11/17 at 3:30 p.m., the Director of Admissions (#7) confirmed that medical record #21 lacked documented evidence the facility had obtained an accepting physician and/or the facility prior to transfer.

During an interview with the Chief Executive Officer (#5 - CEO) on 04/13/17 at 11:30 a.m., the CEO confirmed that the facility was unable to locate a policy that was specific to a Memorandum for Transfer form.

Quality Data Review
Review of the facility's Quality Data revealed there was no documented evidence that transfers were being reviewed to ensure that the transfers were appropriate.

Based on review of medical records, review of facility deflection log, policy and procedure review, policy and procedure, bed unit census report review, and ambulance trip report review, and Administrative staff interviews; Riverwoods Behavioral Health System (receiving hospital) refused to accept from referring hospitals within the boundaries of the United States appropriate transfer of individuals who required such specialized capabilities or facilities when the receiving hospital had the capacity to treat the individuals for 5 (#2, #3, #4, #5, & #6) of twenty-five ( 25) sampled patients. The hospital failed to adopt and implement a policy and procedure that addressed EMTALA Recipient Hospital Responsibilities.

Findings were:
Policy and Procedure

Review of facility's policy PC.105, Plan for Provision of Care, issued 10/08, revealed that the Health System is a private, freestanding healthcare facility that specializes in psychiatric and chemical dependency treatment. Inpatient psychiatric care is provided on a 24-hour basis, seven days a week with a 55-bed (facility actually has 85 beds) capacity.


The facility's Deflection Log (requests for transfer form from other acute care hospitals to the facility that were not accepted) for December 1, 2015 through April 10, 2017 was reviewed. There was no documentation on the Deflection Log to indicate that the Admission Staff checked the Units for available beds, determined whether the patient was an inpatient or outpatient, or that any other information was obtained from the calling facilities regarding the following patients:

1. Patient #2
--Review of the medical record from Hospital B (transferring hospital- hospital listed on the Deflection Log) revealed that patient #2 presented to the hospital on 1/27/2016 with a complaint of Suicidal Ideation. The medical record also revealed the ED physician at Hospital "B" placed the patient on a 1013. Documentation revealed the patient's information was faxed to Riverwoods on 1/27/2016 at 11:58 p.m. and that on 1/27/2016 at 7:19 a.m., Georgia Crisis Access line (G-CAL) was contacted and the patient was placed on the state pending board. The transfer form revealed that Patient #2 was accepted by another psychiatric Facility "M" on 1/28/2016.
On 1/28/2016 RWBH Deflection Log documentation revealed Patient #2 (a 37 year old female) was declined due to no insurance. Review of the facility's bed census for the Adult Unit for 1/28/2016 was 27, and 9 beds were available. Transition Unit bed census for 1/28/2016 was 21 and 3 beds were available. The facility had the specialized capability of staff and facilities to treat patient #2 on 1/28/2016.

2. Patient #3
--On 02/04/16, the Deflection Log noted that patient #3 (44 year old female) was declined due to no lifetime psychiatric days.
Review of the facility's Bed census for the Adult Unit was 28 on 02/04/2016, and 8 beds were available. The Transition Unit bed census review revealed the census was 16, and 8 beds were available. Review of facility "C's" (hospital listed on the deflection log) medical record for patient #3 revealed her chief complaint was "Psychiatric Evaluation" ...Pt reports racing thoughts and trouble concentrating, denies any SI/HI." The ED physician placed the patient on a 1013. Physician orders and nurses notes revealed patient #3 was admitted to facility C ' s inpatient unit on 02/04/16 at 6:26 a.m. Nurses' notes revealed Riverwoods was contacted on 02/04/16 at 2:00 p.m. for "Next Step ". Nurses 'notes revealed Riverwoods declined the patient on 02/04/16 at 4:46 p.m. Nurses' notes revealed the patient was discharged on 02/05/16 with instructions to follow-up with an outpatient program. The facility had the specialized capability of staff and facilities to treat patient #3 on 02/04/2016.

3. Patient #4
--On 3/17/16, the Deflection Log noted that patient #4 (54 year old male) was declined due to no insurance.
Review of the facility's bed census dated 3/17/2016 for the Adult Unit the census was 31, and 5 beds were available. The Transition Unit bed census dated 3/17/2016 was 16 and 8 beds were available.
Review of facility D's (hospital listed on the deflection log) revealed the he presented to the hospital on 3/16/2016 at 2:43 p.m., for a psychiatric evaluation due to suicide attempt. The medical record for patient #4 revealed the ED physician placed the patient on a 1013. Nurses' notes on 03/17/16 at 9:40 a.m. nurses' notes indicated that the nurse spoke with someone at Riverwoods and was informed that Riverwoods could not accept the patient because the patient was on the state contract board with G-Cal. The physician wrote orders for the patient to be sent to psychiatric facility M or N. The transfer form revealed the patient was accepted and transferred to facility N. The facility had specialized capabilities of staff and facilities to treat Patient #4 on 3/17/2016.


4. Patient #5
--On 01/12/16, the Deflection Log noted that patient #5 (43 year old male) was declined due to Traditional Medicaid.
Review of the facility's bed census report dated 1/12/2016 for the Adult Unit was 32, and 4 beds were available. The Transition Unit bed census report dated 1/12/2016 was 26 (2 beds were moved from the Adult Unit to the Transition Unit), the unit had 2 beds available. Review of Patient #5's EMS report dated 1/7/2016 at 2:55 p.m., revealed the patient's Complaint was "Elevated Blood Pressure, Dizziness." The EMS documented the patient's Blood Pressure was 194/112 (normal BP optimal 120/80); Pulse 120 (normal 60-100). The medical record from Hospital "E" (referring Hospital-listed on the Deflection log) for patient #5 revealed an appropriate MSE was completed the ED physician. Further review revealed the ED physician placed the patient on a 1013 on 01/07/16. Documentation revealed that on 01/07/16 information was faxed to Riverwoods and that the patient was placed on the G-Cal board for placement at psychiatric facility M or N. Documentation revealed information was faxed to Riverwoods and other psychiatric facilities again on 01/09/16 and 01/10/16. On 01/10/16 at 9:38 a.m., nurses' notes indicated that the nurse spoke with someone at Riverwoods and was informed that the facility did not accept Traditional Medicaid. On 01/10/16 at 8:46 PM., the physician noted that the 1013 was rescinded and that the patient was discharged back to a group home. The facility had specialized capabilities of staff and facility when Hospital "E" called requesting a transfer for psychiatric treatment of Patient #5 on 01/7/2016, 01/09/2016 and 01/10/2016.


Patient #6

--On 12/27/15, the Deflection Log noted that patient #6 (31 year old male) was declined due to Traditional Medicaid.
Review of the facility's census report dated 12/27/2015 revealed the census for Adult Unit was 32, and 5 beds were available; and the Transition Unit was 0 (closed).
Review of facility "F's" (hospital listed on the deflection log) medical record for patient #6 revealed that the patient presented to the ED on 12/27/2015 with complaint of "Expressing desire to injure others and pacing." Documentation revealed the ED physician placed the patient on a 1013. Documentation also revealed the patient was placed on the G-Cal board on 12/26/15. On 12/27/15 the nurse noted that Riverwoods refused the patient due to standard Medicaid. The patient was accepted at facility "O" on 12/27/15. The facility had specialized capabilities of staff and facility to provide transfer for Patient #6 on 12/27/2015.


Interviews
During the entrance on 04/10/17 at 10:00 a.m. in a physician ' s office, the CEO (#5) and the Director of Nurses (#6) explained that the Admission Counselors perform the MSE on all patients who present requesting treatment and that the Admission Counselors also receive calls for request to transfer patients from other facilities. Both interviewees stated the facility provided services 24 hours a day and that patients presented either as walk-ins or by ambulance from other facilities. They explained that the facility was licensed for 85 beds and that the facility had four (4) units as follows:
--Adolescent Unit was a 12 bed unit for patients that were 10 to 18 (or in High School) year olds;
--Adult Unit was a 36 bed unit for high risk patients that were 19 to 64 years old;
--Transitional Unit was a 24 bed unit for lower risk patients that were 19 to 64 years old; and
--Legacy (Geriatric Supportive Care) Unit was an 18 bed unit for 65 years or older.


During an interview on 04/12/17 at 11:45 a.m. in a physician's office, the Medical Director (#3) explained that he/she had been with the facility since 01/2016 and was mainly at the facility's sister location. The physician said that he/she was familiar with EMTALA regulations but had never had any formal EMTALA training. The Medical Director stated physician (#19) was responsible for the Riverwoods on-call schedule. The Medical Director confirmed that the only reason the facility should not accept a request for transfer would be based on capacity (no available bed) or capability. The Medical Director stated capability would be based on a patient's medical acuity for example patients who required tube feedings or dialysis which the facility could not provide.

The facility failed to adopt and implement Policies and Procedures that addressed EMTALA Recipient Hospital Responsibilities.