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Based on policy and procedure review, medical record review, and interview, it was determined the facility failed to accept an appropriate transfer for one of one (#1) patient requiring specialized psychiatric services not offered by the transferring facility related to (R/T) potential COVID-19 exposure and/or positive test results. By not accepting Patient #1 the facility delayed the specialized treatment needed for Patient #1. The failed practice had the likelihood to affect any patient needing the specialized services provided by the facility for acute psychiatric treatment. Findings follow:

A. Review of Wadley Regional Medical Center Hope (WRMCH) BHC (Behavioral Health Center) policy and procedure titled "Admission Criteria" revised 06/08/21, showed the following,
1) Individuals admitted will have a diagnosis of a psychiatric disorder with at least one admission criteria (65 years old or older. (younger age patient may be considered based on their individual needs and the needs of the behavioral unit).
2. Demonstrates a danger self, others or property.
3) Hallucinations
4) Increased confusion
5) Aggressive behavior
6) Manifest major impairment in activities of daily living and in occupational functioning.
7) Demonstrates continued decline in functioning manifested by impairment in ability to provide for his/her basic physical needs.
8) Condition prevents him/her from benefiting from less intensive levels of care.
9) The patient must be medically evaluated and cleared of co-morbid medical conditions that may be contribution to the psychiatric condition prior to an acute inpatient psychiatric admission such as:
a. Complete Blood Count
b. Comprehensive Metabolic Panel
e. Chest X-ray (CXR)
f. Blood Alcohol Level is applicable
g. Drug levels as indicated by home medications
h. Electrocardiogram


B. Review of WRMCH BHC policy and procedure titled "Infection Prevention and Control Recommendations for Healthcare Personnel during COVID-19 Pandemic" revised 08/08/22, showed all GeroPsych (Geriatric Psychiatry) patients will require PCR (polymerase chain reaction) COVID test prior to admission to the BHU (Behavioral Health Unit) and test from another facility would be accepted as determined by the admitting physician.

C. During an interview on 09/12/22 at 2:15 PM, when Surveyor asked for documentation of denied referrals to WRMCH BHC the Inpatient Director stated, " Currently we do not keep documentation of referrals that do not meet qualification."
D. During an interview on 09/12/22 at 2:32 PM, Inpatient Director confirmed the findings in A and B.

E. Review of Patient #1 Clinical record from the transferring facility BHMC (Baptist Health Medical Center) Malvern showed the following:
1) Admitted in the ED (Emergency Department) on 02/19/22 at 8:04 PM,via EMS (Emergency Medical Services) with a diagnosis of hypertension, suicidal ideations, worsening depression, and history positive COVID-19 January 2022.
2) RN assessment on 02/19/22 at 8:06 PM showed complaints of "wanting to die" and NAD (No Acute Distress)
3) On 02/19/22 at 8:58 PM-Rapid and PCR COVID-19 negative results
4) ED Blood Pressures (BP) showed the following examples:
a) On 02/19/22 at 8:06 PM BP was 191/59
b) On 02/19/22 at 8:15 PM BP was 139/106
c) On 02/19/22 at 8:45 PM BP was 197/71
d) On 02/19/22 at 11:00 PM BP was 197/69
e) On 02/20/22 at 12:45 AM BP was 197/67 after receiving her antihypertensive medications Lisinopril 10 mg(Milligrams) and Amlodipine 10 mg orally.
f) On 02/20/22 at 2:00 AM BP was 170/51
g) On 02/20/22 at 7:30 AM BP was 180/86 upon discharge
5) On 02/19/22 at 11:58 PM care notes showed WRMCH BHC declined patient due to not having an official CXR reading.
6) On 02/20/22 at 2:38 AM- Acceptance to admission to Baptist Southwest Campus Gerophysch
7) Provider note dated 02/20/22 at 5:50 AM showed BHMC Malvern RN was communicating with WRMCH BHC LPN (Licensed Practical Nurse) to transfer patient.
8) There was no evidence of BHMC Malvern Provider to WRMCH BHC Provider communication during the hospital ED admission.
9) On 02/20/22 at 6:01 AM- CXR final reading
10) On 02/20/22 at 7:45 AM, the patient was discharged and transferred via EMS

F. In a telephone interview with the Hospitalist #1, on 09/12/22, at 3:00 PM, when Surveyor #1 asked the Hospitalist #1 to explain admission process and acceptance of transfer request, they stated the following:
1) "The Geropsych unit requires the patient that is requiring admission to have the following:
a) The patient must have a stable chronic condition.
b) A negative PCR test for COVID-19 result.
c) The patient must be age 65 or older.
2) During the last two years, we accepted the consulting provider medical clearance except for not accepting a COVID-19 Rapid test negative result. There has only been one time since the policy changed to PCR results only for COVID-19 that I had any pushback. After accepting the patient, the consulting provider was informed of the requirement for a PCR result. The provider did not like the information. After the call ended, I did not receive any other information regarding transferring the patient to the Geropsych unit."