HospitalInspections.org

Based on reviews of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to enforce policies and procedures for reviewing requests for transfers of pediatric patients with psychiatric emergencies. The hospital failed to accept three pediatric patients with psychiatric emergencies from outside sources even though the hospital had bed availability at the time the requests were made. (Patients #1, #2, and #3).

Based on review of hospital policies and procedures, patient medical records and staff interviews, it was determined the hospital failed to comply with the requirements of 42CFR 489.24(f), responsibilities of Medicare receiving hospital. The hospital did not have written policies and procedures for reviewing requests for transfers in and failed to accept three pediatric patients with psychiatric emergencies from outside sources even though the hospital had bed availability at the time the requests were made. (Patients #1, #2, #3) This deficient practice poses a risk to the health and safety of pediatric patients experiencing a psychiatric emergency requiring admission and treatment.

Finding Include:

The hospital's policy titled, "Patient Transfer - PCH Receiving" (effective 12/1/2017), included: "REASON FOR POLICY...1. To ensure a process for access to treatment at Phoenix Children's Hospital (PCH)...2. To ensure transfer processes are in compliance with Federal and State regulations...POLICY...1. Prior to acceptance, the One Call Admission Center must be contacted to coordinate all patient transfers. 2. Prior to transfer from a another facility, the One Call Admission Center staff ensures appropriate availability of bed space and qualified medical/nursing personnel to protect the health and safety of the patient. "...The transfer is refused if: a.) A patient bed is not available, b.) Qualified medical/nursing personnel are not available, c.) A patient is better served at an adult facility ...."

The "Medical Staff Rules and Regulations" effective 2/01/2020 included: "HOSPITAL ADMISSION...A...The Hospital shall admit patients, provided that facilities are available for care of the patient and protection of Hospital personnel...P. The One Call Admission Center will place patients based on the inpatient acceptance algorithm and using the following order of priorities:...1. Emergency Admissions: Those patients who are designated by the attending physician as patients who need immediate hospital care and whose condition would suffer if admission were delayed."

The "Inpatient Psychiatry SCOPE OF SERVICE-DIRECT PATIENT CARE" document included: : "...Criteria for entry to service admission: Children are appropriate for admission to the inpatient program if the following criteria are met: If the child has been evaluated by a licensed clinician and demonstrates symptomatology consistent with a DSM-V diagnosis and there is evidence of actual or potential danger to self or others that currently and severely impairs the child's ability to function in the family, education, and/or community setting, such as but not limited to...A. Impaired reality testing...B. Dangerous/disordered behavior...C. Mood disregulation...D. Compromised communication and/or relatedness...E. Anxiety...F. Phobia(s)...G. Compulsion(s)/obsession(s)...H. Poorly modulated activity level...I. Severe impulsivity...J. Autistic Spectrum Disorder." The document also included: "A child may not be considered appropriate for admission to the Child Psychiatry Inpatient Program if he/she: A. Has a chemical dependency problem...B. Is sexually active...C. Is an adjudicated delinquent...D. Is overtly aggressive and taking into account the safety of peers, staff is unable to ensure all patient's safety on the unit...E. Patient is not able to participate in the milieu and therapeutic programming as determined by their communication skills and development level of function...F. Is not medically stable as determined by the Attending Physician(s)...."

There was no documentation in the Medical Staff Bylaws / Rules and Regulations that addressed the responsibilities of the qualified medical professional, in this case, the psychiatry staff, when there is a request from an outside source to transfer a patient with an emergency psychiatric condition and specifically during the night. The hospital did not have policies and procedures for reviewing requests for transfers in of pediatric patients with psychiatric emergencies. There was no policy and procedure that required a "packet" of documentation to be submitted from the requesting hospital prior to the transfer of a psychiatric patient or a policy that addressed a time frame in which those packets were required to be reviewed by a qualified medical person.

Patient #1:

Patient #1, who was under the age of 11 years of age, was taken by Emergency Medical Services (EMS) to Hospital #1 on 06/30/2020 at approximately 5:44 p.m. Hospital #1 is a Critical Access Hospital located in a rural community approximately 150 miles from Phoenix. The hospital does not have the capability of providing the specialized services required by a pediatric patient experiencing a psychiatric emergency. The nursing triage assessment revealed the patient was alert, oriented, calm and cooperative at the time of arrival. The patient was accompanied by his case worker who reported the patient had punched a younger sibling in the face earlier in the day and then attempted to strangle the sibling later in the afternoon. The patient told the social worker that he "was going to kill" the sibling. The Emergency Department (ED) physician performed the medical screening examination at 6:09 p.m. The physician's documentation included: "...Patient...presenting to the emergency department with case workers with complaint of homicidal ideation. Patient has been chasing (sibling) around the house with a knife to kill...Patient has a psychiatric history...was sent to Georgia for 9 months for inpatient psychiatric care for similar episodes to this. He had been doing well until the last few days and now mother is concerned that he is not safe to take home. She is concerned that he is going to harm someone or himself and is bringing him here for assessment for inpatient evaluation." The ED physician's physical examination included: "Psychiatric: Thought was coherent, not delusional, not paranoid, with no flight of ideas and with no rambling conversation. Affect was appropriate. There were no visual hallucinations or auditory hallucinations. Insight was normal. Judgement was normal...DIAGNOSTIC CONSIDERATIONS: Anxiety, Depression, Homicidal, Panic disorder and Personality disorder."

The clinical record from Hospital #1 included a "Crisis Risk Assessment" performed at the patient's residence earlier in the day after the family member called 911 because of the behaviors documented above. When law enforcement arrived, the community's Crisis Intervention Mobile Team was activated. The crisis risk evaluator documented the patient's risk of being a danger to others was "Severe." The primary diagnosis documented in the assessment was: "Disruptive mood dysregulation disorder. The evaluator also documented: "Research for a facility to place with him ensued at (name of mental health provider) office. A bed was found at Phoenix Children's Hospital in Phoenix. Arrangements made for the transfer. Paperwork faxed to LPRHED (Hospital #1) and to PCH (Phoenix Children's Hospital)...

The following sequence of events were documented in the nursing notes of Hospital #1:

-06/30/2020: "2140 (9:40 p.m.) spoke with [name] nursing supvs (supervisor) at phoenix childrens, they received patient packet and will send it to the psychiatric dept but do not anticipate a response until the morning, spoke with (name of crisis risk evaluator) and she states that phoenix childrens told her they had a bed for him but needed the pt packet...pt waiting placement to a level 1 facility for Homicidal ideation ...."
-07/01/2029 at 12:58 a.m.: "...called...Crisis center to touch base regarding placement...(Crisis Center) is telling us that he is accepted at phoenix childrens and phoenix childrens is saying he is not accepted at this time, asked the question why they are not trying to find placement for pt in Yuma or Tucson and was told that we were welcome to try...pt has been calm and cooperative all shift."
-07/01/2020 at 10:22 a.m.: "(PCH Staff #12) intake nurse from PCH (Phoenix Children's Hospital) called to inform the RN that they need a Covid testing done before the pt gets admitted to their facility, the intake nurse was informed that we do not have a rapid testing for COVID-19. [PCH Staff #12] stated that they will not be able to admit him without a negative COVID-19 test results ...."
-07/01/2020 at 4:16 p.m.: "Spoke with (PCH Staff #6 and #12) about them requesting COVID testing prior to accepting. We performed test and it was negative and discussed need for PCR as it would take more than 48 hours to get result. This writer advised (sic) that it is not safe for a pediatric patient to be waiting in the ED for 3-4 days. (PCH Staff #6) stated she would discuss with (PCH Medical Staff #1) and return call. Received call at 1605 (4:05 p.m.) and spoke with (PCH Staff #6) again - she advised (sic) that (PCH Medical Staff #1) would not accept patient because 'she was no sure that PCH was the best place for this patient and that we should call (name of another behavioral health hospital)....' "
-07/01/2020 at 5:28 p.m.: "...LC Coronavirus (COVID-19) performed.
-07/02/2020 at midnight: The nurse documented Patient #1 went into the bathroom and filled urinalysis cups with water which upset his mother. The documentation included: "...mother wants to give up temporary custody of patient to DCS (Department of Child Safety) so that she could go with her other child however DCS will not accept him."
07/02/2020 at 2 a.m.: "...pts mother outside crying...because she is tired and worried about her daughter at home."

Up until this time, the patient was described as "calm," "appropriate," and "cooperative," The patient's behavior started to deteriorate at approximately 3:30 a.m. on 7/2/2020. The patient refused to sleep on the bed, threw himself on the floor and pushed the call light every five to ten minutes. The nursing documentation at 4:10 a.m. included: "pt having an emotional breakdown, reports he is hearing things, pt hitting his head...." The patient was described to be "cooperative," "attentive," "appropriate," and calm at 9:58 a.m., however, the documentation at 20:29 a.m. included: "the pt appears to be getting agitated, trying to hurt himself intentionally drift out of the bed with head facing the floor....."

Staff #1 from Hospital #1 documented that Medical Staff #1 from Phoenix Children's Hospital called at approximately 2:35 p.m. on 07/02/2020 and called Hospital #1's ED physician (Medical Staff #5) be present during the telephone call. The documentation included: "Per Dr (PCH Medical Staff #1) PCH has strict rules about admissions and a PCR test is needed to r/o COVID. Asked if they had bed available, she confirmed that they had a bed available but that didn't mean the patient was accepted. This writer asked what was needed for child to be accepted, (PCH Medical Staff #1) said that child needed a negative COVID-19 PCR test and that she did not think child met inpatient criteria. Clarified that Phoenix Children's Hospital had a pediatric bed available, with pediatric psychiatrist available and still refusing this child for evaluation and treatment, (PCH Medical Staff #1) replied 'Yes.'"

Medical Staff #5's (from Hospital #1) documentation dated 7/2/2020 at 6:27 p.m. included: "We have had contact with numerous agencies today regarding this child. Phoenix Children's Hospital refused to see the patient because he did not have a covid test. When we questioned the feasibility of that argument the events that they did not believe is a psychiatric issue although they never evaluated him. My next call was to department children family services who declines to take him out of the house although they feel that both children should be removed. I have also been in contact with...probation officer. The child is not currently on probation although he does have 2 charges pending. 2 representatives from (crisis intervention provider) came out and together with him I sat down with the mother and the patient and worked out a safety plan which I believe that I can sign off on. The child has agreed to stay in the house and not leave without permission, no resulting (sic) behavior towards the mother or the sibling. The mother also agrees to lock up all weapons inside a locked box which they have at the house." The patient was discharged home, which was approximately 60 miles from Hospital #1) on 07/02/2020 at 6:27 p.m.

Phoenix Children's Hospital's "Transfer Center" maintained documentation of requests for transfers from outside sources on a "TeleTracking" form. The TeleTracking form for Patient #1 included the following notes:

-06/30/2020 at 10:18 p.m. from Transfer Center intake staff (Staff #13): "Notification sent:...Hello, you have a new patient case to review. Please login to TeleTracking and review the case. This pt has a Narrow Network Insurance. Please involve PCH financial counselors if pt is to be accepted. Recipients: (Names of Medical Staff #1, #3, and #4)"

07/01/2020
-9:31 a.m. (over nine hours later): The psychiatry provider on-call 06/30/2020 (Medical Staff #2) documented: "Will need COVID test." The recipients of this note was documented to be "Placement, Patient."
-10:13 a.m.: An intake nurse (Staff #12) documented: "RN requested COVID 19 testing. should call with results."
-10:20 a.m.: Staff #12 documented: when called stated does not have rapid testing at facility. will call us back if they can figure something out.
-12:58 p.m.: Staff #12 documented: "covid testing resulted and negative."
-2:37 p.m.: Staff #12 documented: COVID test was incorrect test. Needed PCR testing, witch (sic) send facility stated they did not have. Then stated mom was going to leave AMA."
-4:07 p.m.: The Director of Patient Logistics (Staff #6) documented: "Spoke to (Name of CNO at Hospital #1). (Name of Hospital #1) is under the impression (it's documented in crisis workers notes) that PCH accepted patient and they are concerned because patient has been in ED for close to 24 hours. (Staff #2) had explained that (Medical Staff #1) wanted a PCR covid test vs the antigen and (name of Hospital #1) does not do that. I spoke with (name of CNO at Hospital #1) and let her know that I would confirm this with (name of PCH's Chief Quality and Patient Safety Officer) and work on a plan and call her back. Spoke with (name of PCH's Manager of Inpatient Psychiatric Unit) and she stated that the covid was not the issue holding back, but that (Medical Staff #1) wasn't sure that we were the right place for the patient...states that (Medical Staff #1) will review the packet again in the morning. I called (name of CNO at Hospital #1) back and relayed this information.:
-12:09 p.m.: Medical Staff #2 documented: "Inpatient psych patient declined."
-2:46 p.m.: Medical Staff #2 documented: "...Spoke with the CNO...and the ED physician at (Hospital #1). Reviewed current COVID admission requirements. Also discussed that based on clinical information provided that patient does not appear to meet inpatient criteria...."

Staff #6 reported during an interview on 7/13/2020 that patients from outside facilities are not admitted to the psychiatric unit at night because a physician is required to complete an evaluation within one hour of the admission, and they do not have psychiatrists to complete the assessments within one hour during the night. Employee #6 also reported that the on-call psychiatry provider was not contacted during the night regarding the request for patient #28 to be admitted to the hospital. Employee #6 confirmed the request to transfer the patient to this hospital was made on 6/30/2020 at 22:18 (10:18 p.m.), and the hospital did not notify Hospital #1 that they declined the patient until 7/2/2020 at 2:46 p.m.

The Psychiatric Division Chief (Medical Staff #3) reported during an interview on 7/13/2020 that the psychiatrists are available by phone 24 hours a day / 7 days a week. He said the packets received from outside hospitals for psychiatric patients who need inpatient admission are "typically not reviewed at night," and the physicians do not continue to check things that come in because they are trying to manage the patient load in their own ED. Medical Staff #3 reported the expectation is for the packets received from other hospitals will be reviewed within 24 hours.

In summary, PCH received the request for transfer of Patient #1 from Hospital #1 on 06/30/2020 at 10:18 p.m. The hospital had beds available on their eleven-bed psychiatric unit as the census at midnight was "5." Staff #3 clarified that Medical Staff #2 reviewed the packed at a"high level" on 07/01/2020 at 9:30 a.m., however, Medical Staff #2 (a Nurse Practitioner) reported s/he can make a recommendation on admission, however a physician needs to agree. Medical Staff #1 (a psychiatrist) reviewed the packet with Medical Staff #2 on 07/01/2020 at approximately 4:07 p.m. Staff #6 advised Hospital #1 that Medical Staff #1 "wasn't sure that we were the right place for the patient," however, Staff #6 also told Hospital #1 that Medical Staff #1, "...will review the packet again in the morning." According to the detailed notes in the clinical record from Hospital #1, Medical Staff #1 from PCH did not call Hospital #1 until 07/02/2020 on or around 2:35 p.m. PCH did not advise Hospital #1 that they were declining the transfer of the patient until 07/02/2020 at 2:46 p.m.

Patient #2:

Patient #2 was taken to the ED at Hospital #2 on 06/12/2020 at 9:56 a.m. The patient who was under the age of 13 years, was brought in by law enforcement after s/he ran away from a group home and was hitting his/her head on the concrete. The patient received a medical screening examination from the ED physician followed by a "Behavioral Health Pediatric Crisis Assessment at 3:17 p.m. The evaluator's documentation included: "...Pt has been inpatient at PCH numerous times...has been diagnosed with Autism spectrum disorder, Mood disorder, ADHD, and ODD. Per records the patient has a history of running into the street (multiple times) and self-harming by hitting her head, swallowing objects, and scratching herself...This is the 2nd presentation to the ED in the past 2 weeks and the patient's self-endangering behavior is escalating. Patient ran into traffic, was almost hit by cars, and was beating head on sidewalk and against police car window/divider. At this time, the patient is an imminent danger to herself and is recommended for Level 1 MHIP for further evaluation and stabilization...."

PCH received a packet for Patient #2 on 06/13/2020 at 12:15 p.m. The "TeleTracking" documentation for Patient #2 included: "...Hello, you have a new patient case to review. Please login to TeleTracking and review the case...." The recipients were Medical Staff #1, #3 and #4. The TeleTracking form included the following documentation: "...Procedure: Packet Sent, still waiting 6/15...Decision Date/Time: 6/16/20: 13:34...Disposition Canceled. Patient sent to another facility by requestor ...." There was no documentation that the packet and request for admission to the inpatient psychiatric unit was reviewed by a medical provider.

Employee #7 confirmed in an interview conducted on 7/13/2020, the referral for a psychiatric bed was received on 6/13/2020 at 12:09 and confirmed that the patient was still waiting for a psychiatric bed on 6/15/2020. Employee #7 was unable to provide documentation to confirm the referral packet was reviewed by a provider. The referral was "canceled on 6/16/2020 at 13:34.

Employee #5 provided documentation confirming the hospital had the following beds available at midnight: four (4) psychiatric beds available on 6/13, two (2) beds on 6/14, three (3) beds on 6/15 and three (3) beds available on 6/16/2020.

Employee #6 and #7 confirmed that One-Call staff do not follow up with the physician's when there is a referral pending.

Patient #3:

Patient #3 who was under the age of 10 years was taken to a behavioral health crisis response provider (Provider #3) on 02/10/2020 at 6:21 p.m. for suicidal thoughts and aggressive, explosive, and harmful behaviors toward family. There were concerns for the safety of the family due to the severity of the patient's behaviors. PCH received the packet from Provider #3 on 02/12/2020 at 13:30 (1:30 p.m.) Documentation on Page 2 of the TeleTracking form dated 02/12/2020 at 1606 (4:06 p.m.) included: "Notification Sent...Hello, you have a new patient case to review. Insurance has been verified. Please login to Tele Tracking and review the case." The recipients of the note were Medical Staff #1, #3 and #4. There was no documentation that the packet was reviewed by a medical provider. Documentation on page 1 of the TeleTracking form included: "Procedure: Insurance OK, pkt forwarded/no answer 2/1...Disposition Canceled...Disposition Reason: Patient Sent to Another Facility by Requestor ...Decision Date/Time: 2/17/2020 09:19 ...."

Staff #6 confirmed in an interview conducted on 7/9/2020, that s/he did not have documentation to identify if the referral packet was reviewed by a physician between 2/12/2020 and 2/17/2020 at 09:19. Staff #6 reported the "Decision Date/Time" on the TeleTracking packet is the time the request for a bed was canceled. Employee #6 confirmed that OneCall staff are expected to communicate with the referring hospital once a day to check the status of the patient and find out if a bed is still needed. Employee #6 confirmed that the TeleTracking form did not contain dates or times the OneCall staff attempted to contact the referring facility to check the status of the patient until 2/17/2020 when the disposition "Patient sent to another facility by Requestor" was entered. Employee #6 reports that the One Call staff do not reach out to the physicians to follow up on the status of the packet once the message is sent.

Staff# 7 confirmed in an interview conducted on 7/13/2020, the referral for a psychiatric bed was received on 2/12/2020 at 13:30. The request for the bed was "canceled" on 2/17/2020 at 0919. Employee #7 was unable to confirm if the hospital contacted the crisis center between 2/12/20 and 2/16/20 to follow up on the status of the patient. There was no documentation to identify the physician reviewed the referral packet.