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2900 SUNSET BOULEVARD

WEST COLUMBIA, SC 29169

COMPLIANCE WITH 489.24

Tag No.: A2400

RECIPIENT HOSPITAL RESPONSIBILITIES

Tag No.: A2411

Based on review of patient intake records,medical record reviews, policy and procedure reviews, interviews, and review of the Hospital A's log, titled, "Flash Legal By Bed" and Hospital A's bed census reports, Hospital A failed to accept from referring hospitals appropriate transfers of individuals with identified emergency psychiatric conditions, that required such specialized psychiatric capabilities of the facility, and the receiving hospital had the capacity to treat 11 (Patient 1, 5, 8, 9, 10, 11, 12, 14, 15, 16, and 17). of 20 patient charts (intake records) reviewed. The facility also failed to have an effective policy and procedure that addresses EMTALA acceptance of appropriate transfers from transferring hospitals.

The findings are:

Policies and Procedures
Hospital A's Policy and Procedure , titled, Patient Transfer From Another Facility Clinical Services, CC. 005, with an effective date of October 2000 and a revised date of November 2009, reads,
Policy: It is the policy of (Hospital A) to provide for appropriate transfer of patients from another facility for admission to (Hospital A).
Procedure:
1. Patients may be accepted for transfer under the following circumstances:
A. The patient's emergency condition has been stabilized to the extent possible by requesting facility.

B. The patient meets approved criteria for admission at the level of care for which admission is requested.

C. The ability to provide structured behavioral health care treatment of the specific emergency medical/psychiatric condition (i) is not available in the transferring facility or (ii) is not authorized by the managed care provider or other third party payor and (iii) the patient requests and/or has consented to the transfer.
D. The admitting physician or NARC Counselor has directly communicated with the transferring facility to establish the need for transfer and has agreed to accept responsibility for the patient's continuing treatment.
E. Admission is approved by the CEO or his/her authorized administrative representative, except for emergencies. [The circumstances for patient transfer should be thoroughly reviewed with the CEO by the admitting physician.]

2. Admission documentation on all transfers should clearly indicate the specific criteria met for admission and the clinical condition of the patient upon arrival at the facility.

3. Except in an emergency, to the extent possible, transfers should take place only during regular business hours unless authorized by the CEO or his/her designee. A nursing report from the transferring facility should be given to a (Hospital A) nurse whenever possible.

4. The patient should be assessed upon arrival to the facility by the Needs Assessment Counselor or Registered Nurse and the following performed:
A. Confer with and obtain pertinent information from the admitting physician related to the patient's clinical condition and the appropriateness of the transfer using admission criteria.

B. In the event that the transfer was emergent, obtain administrative approval for the transfer as soon as possible from the CEO or his/her authorized representative.
C. Fully document all pertinent patient data on the TRIMS form, including the process for the patient transfer as soon as possible from the CEO or his/her authorized representative.
D. Initiate and complete admission procedures as appropriate.

Record Review
Patient 1
On 07/14/15 at 2:40 p.m., review of Patient 1's intake record from Hospital A revealed Patient 1 was referred on 06/26/2015 to Hospital A(receiving hospital) from Hospital B's (hospital requesting transfer) emergency department for admission for an identified psychiatric emergency medical condition.
Review of Hospital A's intake form dated 06/26/2015 at 15:40 revealed the patient's name, date of birth, and presenting problem as"Schizophrenia" and legal status was "involuntary". Review of the intake form's disposition section, revealed, "Closed disposition; Non - Clinical/ No Care Recommended; Reason for Non - Admit: "Not Clinically Qualified"; Intake Explanation: "Declined Dr. (Psychiatrist from Hospital A)". In the comments section on Hospital A's intake form was recorded,"06/26/15 PS: ..... (name of person from Hospital B) refused to send the insurance information, stated that he wanted it staffed, and then he would give us the insurance information. I told him no problem that I had already given the doctor the info, and was waiting on a decision. In the mean time, I was just trying to complete my work, and that is the only reason I asked for the insurance. I staffed with Dr. (psychiatrist from Hospital A). He(psychiatrist from Hospital A) declined - Not clinically appropriate. Referral(Hospital B) then wanted to know why Pt.(Patient) wasn't clinically appropriate and requested that Dr. (psychiatrist from Hospital A) call and speak with the doctor. " There was no evidence presented that this conversation between the physicians at each hospital occurred.

Review of Hospital B's(Hospital requesting transfer) emergency department history and physical revealed Patient 1 presented to Hospital A's emergency department on 06/24/2015 with no time of presentation recorded on the document. The document revealed the patient arrived in the emergency department via Emergency Medical Services(EMS) and the Chief Complaint was documented as (Detention Order). In the section labeled, " History of Present Illness", the physician documented, " The patient is a 52 year old man with a past medical history noted for Schizophrenia who currently, per family and detention report, noncompliant with medication, neglecting self care, not bathing, not changing clothes, talking to himself, responding to unseen stimuli with increased paranoia, agitation, and a staying in a tool shed on a vacant lot with no windows, running water, or electricity, in a dark room. The patient himself states that he is doing well with no acute complaints." The section for physical examination was benign and the urine drug screen was negative.

Review of Hospital B's emergency room physician's statement in the section, labeled, "Medical decision Making/Emergency Department Course" showed, "Considering the patient's signs, symptoms, and clinical presentation, a thorough history and physical exam was performed. The patient remained well - appearing with normal vital signs. He had a very concerning report, per the distention[sic] order record. He was seen by mental health consultants and will be evaluated by a psychiatrist in the morning. Notably, the patient has had prior hospitalizations at psychiatric facilities; 1997 was his last admission to with 3 overall lifetime admissions as well as the state hospital in 1990. The patient is agreeable to the course and plan, and agreeable to waiting for further evaluation. Diagnoses/Impression: 1. Detention order. 2. Schizophrenia. 3. Paranoia."

Review of Hospital B's psychiatric consultant's report dated 6/25/2015 at 09:55 a.m. revealed the section, labeled, Medical Decision Making, with documentation that stated, "Patient was seen for psychiatric evaluation after being medically cleared by the ED (emergency department) physicians. Patient was placed on involuntary commitment last night by the ED physician after being brought in on a detention order. He has been noncompliant with outpatient psychiatric treatment and has omitted caring for his ADL's (Activities of Daily Living). He has poor insight and need psychiatric stabilization. He will be held and psychiatric medications restarted."

Review of Hospital A's licensed bed capacity report for 6/26/15 and Flash Legal By Bed reported dated 6/26/15 revealed:
Adult Unit: 36 total beds with 34 beds occupied;
CSU: 38 total beds with 13 beds occupied; and
Geriatric Unit: 28 total beds with 9 beds occupied.
Hospital A had the capacity to admit Patient 1 on 6/26/2015 when the referral was made from Hospital B.

Patient 5
On 07/15/15 at 10:15 a.m., review of Patient 5's intake record from Hospital A revealed the patient, age 15, was referred for admission for an identified psychiatric emergency medical condition to Hospital A from Hospital D on 05/02/15. Review of the patient's intake record from Hospital A identified Patient 5's "Presenting Problem: suicidal attempt" and "legal status: involuntary". The documentation on the form showed Hospital A's "reason non-admit: no beds available". Review of Hospital A's census report for 5/2/15 showed Hospital A's adolescent unit had a bed capacity of 16. Review of Hospital A's form, "Flash Legal By Bed", revealed 15 beds were occupied on 05/02/15 which left 1 bed vacant on 05/02/15.

Patient 8
On 07/15/15 at 10:35 a.m., review of Hospital A's intake record for Patient 8 revealed the patient, age 25, was referred to Hospital A from Hospital F's ER (Emergency Room) on 05/30/15.

Further review of the forms attached to the patient's intake record from Hospital A revealed the patient's ED history and physical report performed on 05/29/15 from Hospital F. Review of the data from Hospital F's assessment revealed the patient presented to Hospital F with suicidal ideation. The documentation revealed, "The patient was found in the middle of the roadway sitting in traffic saying he wanted to die. The course/duration of symptoms is constant. Character of symptoms agitated suicidal thoughts. The degree of symptoms is severe. Self injury none. The relieving factor is none. Risk factors consist of suicide risk. Prior episodes: occasional. .....".

Review of Hospital A's intake form dated 5/30/15 showed the patient's "presenting problem: Suicidal attempt" and "legal status: involuntary". The reason given for Hospital A's action for non-admit, read, "refused action financ" with written comments, "Pt has SI(suicidal ideation) with a plan to get hit by a car. Pt (Patient) has medicaid. No beds available".

Review of Hospital A's bed census data for 5/30/15 revealed Hospital A's
Adult Unit had a bed capacity of 36 with 16 beds occupied;
CSU had a bed capacity of 38 with 28 beds occupied; and
Geriatric Unit had a bed capacity of 28 with 23 beds occupied.
Review of Hospital A's "Flash Legal By Bed" report for 05/30/15 revealed Hospital A had:
16 beds occupied on the Adult unit which left 22 beds vacant;
28 beds occupied on the CSU which left 10 beds vacant; and
23 beds occupied on the Geriatric unit which left 5 beds vacant.

Patient 9
On 07/15/15 at 10:40 a.m., review of Patient 9's intake record from Hospital A revealed the patient, age 34, was referred from Hospital G's ER on 06/08/15. Further review of Hospital A's intake form revealed Patient 9's "Initial ED(Emergency Department) Consult" from Hospital G was performed on 06/07/15 from Hospital G.

Review of the emergency room assessment data from Hospital G for Patient 9 showed the patient presented to Hospital G's emergency department stating that he was suicidal and threatening to overdose on Seroquel (medication given for sleep). Review of the section of the form, titled, "History of Present Illness" showed the physician documented," The patient is a 34 year old male who has been seen by telepsych on 10 previous occasions within the past 2 years. He was brought to the ED by the administrator of a religion based substance abuse treatment program called ...... after being kicked out of the program today. He had been at this program for 90 days and had hoped to get into housing provided by them tomorrow when he was told he would not. He says he is depressed and will kill him self if he cannot stay in the hospital. He is homeless and has no where to go. He says that there are no shelters available. Placement for him is difficult as he is a registered sex offender. He says he has a home in Great Falls but it has no power and water. Initially stated that he had been doing "fine" at the treatment program, but when I began discussing discharge with him, he claimed to have been having racing thoughts and hearing voices telling him to kill himself. Has presented in a similar fashion to the ED many times in the past. He has had a history of multiple arrests." The ED physician completed the Certificate of Licensed Physician Examination For Emergency Admission" form dated 6/7/15.

Review of Hospital A's intake form dated 6/8/15 for Patient 9 revealed, "Presenting Problem: suicidal ideation" and "legal status: involuntary". The reason documented for "reason non-admit: not clinically qualif" with comments that read, "declined by Medical Director, lacks acuity for I/P(inpatient) treatment".

Review of Hospital A's bed census report dated 06/08/2015 revealed:
Adult unit had a bed capacity of 36;
CSU had a bed capacity of 38; and
Geriatric Unit had a bed capacity of 28.
Review of Hospital A's "Flash Legal By Bed" report revealed that on 06/08/15:
Adult Unit had 33 beds occupied beds which left 3 beds vacant;
CSU had 28 occupied beds which left 10 beds vacant; and the
Geriatric unit had 11 beds occupied which left 17 beds vacant.

Patient 10
On 07/15/15 at 12:30 p.m., review of Patient 10's intake record from Hospital A revealed the patient, age 15, was referred via fax to Hospital A from Hospital H's Emergency Department on 06/17/15.

Review of Hospital H's emergency department physician documentation revealed Patient 10 presented to Hospital H's emergency department on 6/17/15. The patient's father and stepmother transported the patient to the emergency department for a psychiatric evaluation for violent outbursts, threatening to kill his family, and destroying the house. The emergency room documentation showed the patient had a history if ADDH (Attention Deficit Disorder Hyperactive), was abused by his mother, and was touching the stepmother inappropriately. The emergency department physician documented that a phone consult was initiated with Dr...... on 6/17/15/at 2122 who recommended the patient to be committed, will place patient on white papers, and will see patient in the Ed.

Review of the intake form from Hospital A revealed the patient's "ED HPI (History and Physical Information)" was performed on 06/17/15 by Hospital H. The intake form from Hospital A revealed Patient 10's: "Presenting Problems: homicidal thoughts" and "legal status: involuntary" for the "reason non-admit: not clinically qualif" with comments that read, "....pt declined due to pending felony charges which is automatic denial criteria....no appropriate beds available....".

Review of Hospital A's bed census report for 6/17/15 showed the Adolescent unit had a bed capacity of 16. Review of Hospital A's "Flash Legal By Bed" report for 6/17/15 revealed 12 beds were occupied which left 4 beds vacant on 06/17/15 on the Adolescent unit.

Patient 11
On 0715/15 at 12:35 p.m., review of Patient 11's intake record from Hospital A revealed Patient 11, age 50, was referred to Hospital A from Hospital I's "Emergency Center" on 07/06/15.

Review of the data from Hospital I that was sent with with Hospital A's intake report revealed Patient 11's presented to Hospital I's emergency department on 7/3/15 Emergency Services transport with bizarre behaviors, wandering streets, singing, dancing, doing yoga, and stating that she was moving forward. Review of the patient's Behavior Health Services Comprehensive Assessment Tool and Social History showed the patient had rapid speech, hyperreligion, vigorously cleaning with a paper towels, and refusing to answer questions. The plan was telepsych and seek inpatient bed. The forms for Emergency Admission for Mental Illness were completed by the emergency department physician.

Review of Patient 11's intake record from Hospital A revealed Patient 11's "Presenting Problems: hallucinations" and "legal status: involuntary" was the reason given as a "reason non-admit: refused action financ" with comments "pt is self pay-homeless".
Review of the bed census report for Hospital A's on 07/06/15 showed
Adult Unit had a bed capacity of 36;
CSU had a bed capacity of 38; and the
Geriatric Unit had a bed capacity of 28.
Review of Hospital A's "Flash Legal By Bed" report for 07/06/15 revealed
Adult Unit had 33 beds occupied which left 3 beds vacant; CSU had 32 beds occupied which left 6 beds vacant; and the
Geriatric Unit had 12 beds occupied which left 16 beds vacant.

Patient 12
On 07/15/15 at 12:40 p.m., review of Patient 12's intake record from Hospital A revealed the patient, age 16, was referred to Hospital A from Hospital J on 07/03/15.

Review of Hospital J's emergency department physician assessment showed Patient 12 presented to Hospital J's emergency department on 7/03/15 at 18:57 with a chief complaint of "I want to kill myself - by inflicting wounds on my arms and hanging." The physician documented that the patient had been discharged from Hospital A three days ago. In the section labeled, History of Present Illness, the emergency department physician recorded, " 15 yo (year old) female with recurrent and chronic auditory hallucinations - telling her to harm self and others, suicidal Ideation, Depression." Review of the patient's chart showed the completed forms, titled, Application For Child In Need Of Emergency Admission" dated July 3, 2015. Hospital A was notified for need of transfer 7/3/15.

Review of Patient 12's intake form from Hospital A showed the referral to Hospital A was made on 7/3/15. Patient 12's presenting problem was listed as depression and the patient's legal status was listed as involuntary. The reason for Hospital A's denial was recorded as "reason non-admit: not clinically qualif" with comments that read, "....No appropriate bed at this time....".

Review of Hospital A's bed census report dated 7/3/15 showed the Adolescent Unit had a bed capacity of 16.
Review of Hospital A's "Flash Legal By Bed" report dated 7/3/15 revealed the adolescent unit had 4 beds occupied on 07/03/15 which left 12 beds vacant.

Patient 14
On 07/15/15 at 3:55 p.m., review of Patient 14's intake record from Hospital A revealed the patient, age 46, was referred to Hospital A from Hospital E's Emergency Department on 06/16/15.

Review of the data submitted by Hospital E revealed physician orders for "ED telepsych consult" entered on "06/14/15 at 21:11", and Patient 14's *HPI-Psychological" was performed on 06/15/15. Patient 14 had forms for Involuntary Emergency Hospitalization for Mental Illness dated June 14, 2015 related to suicidal ideations in the packet. Review of the HPI - Psychological assessment showed the patient presented to Hospital E's emergency department from a community home for noncompliance with medications, having auditory/visual hallucinations, denies SI (suicidal ideation/(HI (Homicidal Ideation). Review of the emergency department nursing assessment showed,"Recently medicated for severe agitation. The patient was found in the dormitory area involved in a tense conversation with hospital security. Security was present due to the patient picking up furniture. Jumping from one bed to the next. Free falling on the mattress."

Review of Patient 14's intake record from Hospital A revealed the patient's "presenting problems: "hallucinations" with "legal status as involuntary". The reason given for declined admission was "reason non-admit: refused action financ".

Review of Hospital A's bed census report for 6/16/15 for:
Adult Unit had a bed capacity of 36;
CSU had a bed capacity of 38; and
Geriatric Unit had bed capacity of 28.
Review of Hospital A's "Flash Legal By Bed" report for 06/16/15 31 showed:
Adult unit had 31 beds occupied which left 5 beds vacant;
CSU had 25 beds occupied which left 13 beds vacant; and
Geriatric Unit had 15 beds occupied which left 13 beds vacant.

Patient 15
On 07/15/15 at 4:00 p.m., review of Patient 15's intake record from Hospital A revealed Patient 15, age 23, was referred to Hospital A from Hospital K's "Department: ER".

Review of the emergency room physician documentation from Hospital K
dated 6/17/2015 revealed the patient walked into the hospital's emergency department at 21:35 pm with chief complaint of anxiety, depression, suicide ideation, and has a plan to jump from a height to shoot self. Was recently seen by Mental Health and told that she might have bipolar illness. She is waiting for an appointment with the psychiatrist. She is on no medication. Has been having intermittent suicidal thoughts that seemed to be worse tonight. ....She is hearing voices....". Involuntary Emergency Hospitalization papers were issued on June 17, 2015.

Review of Patient 15's intake record from Hospital A revealed the patient's "presenting problem: suicidal ideations" with "legal status: involuntary" and the reason given was documented as "reason non-admit: information only" with comments "....had no appropriate beds available for pt at this time".
Review of Hospital A's Adult unit bed census report dated 6/18/15 showed:
Adult Unit had a bed capacity of 36;
CSU had a bed capacity of 38; and
Geriatric Unit had a bed capacity of 28.
Review of Hospital A's "Flash Legal By Bed" report dated 06/18/15 showed:
Adult Unit had 28 beds occupied which left 8 beds vacant;
CSU had 20 beds occupied which left 18 beds vacant; and
the Geriatric Unit had 16 beds occupied which left 8 beds vacant.

Patient 16
On 07/15/15 at 4:05 p.m., review of Patient 16's intake record from Hospital A revealed Patient 16, age 41, was referred from Hospital L's "Emergency Services Department" on 07/11/15.

Review of Hospital L's emergency department notes revealed the patient presented to Hospital L's emergency department on 7/10/15 at 1834 with depression onset one week ago. Review of the emergency physician's HPI Notes from Hospital L revealed," 42 y/o (year old) F(female) reports to the ED(Emergency Department) c/0(complaints of) depression onset one week ago. Pt reports current suicidal ideation and that last Saturday she attempted to overdose on on cocaine. Pt has Hx(history) of alcohol and substance abuse but other than the last episode has been clean. Pt reports hx of bipolar depression but reports her sx (symptoms) have never been this bad. Pt states that she feels it is related to multiple factors in her life but also reports that she has been out of her medications for several weeks. There are concerns at this time."

Review of the intake form for Patient 16 from Hospital A on 7/11/2015 revealed Patient 16's presenting problem was "suicidal ideations" with "legal status as involuntary" recorded as the "reason non-admit: refused action financ".

Review of Hospital A's census report for 7/11/15 revealed:
Adult unit had a bed capacity of 36;
CSU had bed capacity of 38; and
Geriatric Unit had a bed capacity of 28.
Review of Hospital A's "Flash Legal By Bed" report revealed that on 07/11/15:
29 beds were occupied on the Adult unit which left 7 beds vacant;
28 beds were occupied on the CSU which left 10 beds; and
25 beds were occupied on the Geriatric unit which left 3 beds.

Patient 17
On 07/16/15 at 12:05 p.m., review of Patient 17's intake record from Hospital A revealed the patient, age 22, was referred to from Hospital M's "Emergency Department" on 06/27/15.

Further review of the intake sheet from Hospital A revealed Patient 17's "Psychiatric Complaint-ED Provider Note" from Hospital M was collected on 06/26/15.

Review of the emergency department physician notes from Hospital M showed the patient presented to the Hospital M's emergency department with violent assaults against family members. Involuntary Emergency Commitment papers dated 06/26/2015 were filed. Patient 17 received a medical examination and clearance in Hospital M's emergency department. Review of Hospital A's intake form revealed the reason listed for non admit was"Information Only". In the comments section was recorded,"Pt(Patient) was taken to ER by the police. He attacked his grandfather, grabbed and twisted his arm until he broke the skin. Assaulted his grandmother and wife. Pt is on probation Has a $30,000. fine. Has stolen checks from his family members. Staff with Dr. (Physician's Name) Declined admission Pt. is too violent for admission at this time."
Review of Hospital A's bed census report revealed:
Adult Unit had a bed capacity of 36;
CSU had a bed capacity of 38; and
Geriatric Unit had a bed capacity of 28.
Review of Hospital A's "Flash Legal By Bed" report dated 6/27/15 revealed:
31 beds occupied on the Adult unit which left 5 beds vacant;
28 beds occupied on the CSU which left 10 beds; and
21 occupied beds on the Geriatric unit which left 7 vacant beds.

Interviews
On 07/14/15 from 11:45 a.m. until 11:55 a.m., the Chief Executive Officer (CEO) revealed the process for receiving patient referrals from other facilities consist of one of two ways either by telephone or by fax. Once the information is obtained, the Needs Assessment personnel look at the physician list because our limiting factor of accepting patients has not been capacity, but capability based on the number of physicians. We just recently had an influx of physicians, 2 new hires and 1 returning community physician. The Needs Assessment personnel look to see if the physician can handle any more patients or has had a lot of recent admits. Plus, some of the physicians only work with certain units. For instance, if a physician works only the adolescent unit, he/she will not accept a Geriatric patient. The other process is that once the physicians receive the information they may request additional information such as labs before accepting a patient or ask for the facility to hold the patient because the physician doesn't think the patient is stable to transfer or deny the request because the patient is clinically inappropriate. Clinically inappropriate means the patient has too many medical conditions that the psychiatrist may feel would be to difficult to manage at this hospital. Because we are a free-standing hospital, we transfer all our patients with medical conditions/emergencies to a local hospital. The physicians don't want to accept a patient and then, have to turn right around and send/transfer the patient to the local hospital. Another reason is if the patient is too aggressive and will interfere with the milieu of the unit and cause harm to self or others, the physician will deny the patient. The type of personnel that work in the Needs Assessment department are licensed nurses as well as licenses therapists. The only limit to us accepting patients is because we did not have enough doctors. The hospital failed to adopt policies and procedures related to Recipient Hospital Responsibilities that comply with the requirements of 2 489.24 (f) as evidenced by failing to ensure Three Rivers Behavioral Health may not refuse to accept from referring(transferring) hospitals appropriate transfers of individuals that requires such specialized psychiatric capability or facilities if the receiving hospital has the capacity to treat individuals (1,5,8,9,10,11,12,14,15, 16, and 17) with emergency psychiatric conditions.

On 07/15/15 at 9:15 a.m. until 9:35 a.m. Registered Nurse(RN) 2 revealed that the purpose of the "reason non-admit" allow for communication between the Needs Assessment staff in case someone different respond to the fax or call. It gives a drop down box with choices to select related to why the information was received or what we did with the information. For example, we may receive a call just for information or a fax just for information but we still have to log it on the intake log. We can write comments in the comment section if there is not a selection appropriate and that way if another person in the department receive a call on a patient, they will know where that patient is in the process, like waiting on labs, a redraw or CT results. RN 2 stated in regards to patient 1 that "I remember going back and forth with the referring agency and Psychiatrist 2 about this patient. I can't remember the specifics but Psychiatrist 2 decline admitting the patient because Psychiatrist 2 stated that the patient was medically inappropriate. I can't remember the specifics. What determine if there are beds available? We have a bed board with the census of the units and know how many adult beds or adolescent beds are available for that day. What does "refused action financ" mean? I don't know why that drop down choice is being used because we don't refuse any patient for any financial reasons. We staff every patient regardless of finances if a bed is available.

On 07/15/15 from 10:45 a.m. through 11:05 a.m., RN 3 revealed, "reason non-admit" drop down selection of "Information only" tells me that someone called and asked about our program, but did not want to place a patient or did not want to have an assessment or make an appointment. the section, "No beds available" means that we did not have a bed on the unit. The unit was full or the doctors were at their maximum capacity. "Refused Action Financ" means I guess that mean that perhaps they didn't want to come as self pay. We take everyone regardless it they have insurance or not. Maybe the person didn't want to come as a self pay. When we get faxes in from facilities, we staff them with the doctors even if they have no insurance. "In patient intake"means that the patient was admitted to the facility. The closed disposition should state "admit". If there is an "N" for the assessment, I would say that the patient was not admitted to this facility. "Not Clinically qualif"means the patient is not clinically qualified for one of our programs. It could be medical like if there are medical issues or if they are in jail. We do not take direct admissions from jails. The person can come in for an assessment once he/she is released from jail."

On 07/16/15 from 10: 20 until 10:31 a.m., Psychiatrist 1 revealed that the Geriatric unit is a "total care unit" where the patients have to get assistance from staff for showers. It is a dementia unit right now. We try not to put cognitive patients in the area/unit".

On 07/16/15 from 11:40 a.m. until 12:02 p.m., RN 1 revealed, "No beds available" means two things. One: no beds available, or two: which doesn't give us an option because there is no physician availability, but the only choice that would correspond would be no beds." RN 1 explained that the "Refused Action financ(financial)" means that there is a financial situation like self pay or the patient had to pay out of pocket. We would make the agency aware that the insurance required a high deductible and the patient decided not to come in. We accept any patient regardless of pay but even if involuntary, we still have to let the agency know that the patient may have to pay. We just want them to be aware, but we will still bring the patient in. "Not clinically qualif(qualified)" means the psychiatrist makes the ultimate decision on accepting or denying the patient or something within the clinical information that make them unstable for the hospital. We are given a list by our Medical Director of automatic reasons that we can not take patients, such as dialysis patients. We can't care for those type of patients because we are a free standing facility. The section labeled "Information Only" means sometimes the agency or someone from the community of a former patient wants specific information or they are not sure if the patient meets admission criteria, or may not want to come in for treatment, or want other referrals like out patient criteria."

On 07/16/15 from 1:30 p.m. until 1:33 p.m., Psychiatrist 2 revealed Patient 1 was deemed "not clinically qualified" for admission to Hospital A because the physician that completed the patient's evaluation alleged that there were psychiatric issues, but there was no evidence of psychiatric issues upon examination. Psychiatrist 2 stated that the examination states that the patient "denies SI(Suicidal Ideation)/HI(Homicidal Ideation). AV (Auditory/Visual) hallucinations and delusions. " Patient #1's "Application of Involuntary Emergency Hospitalization For Mental Illness"dated 6/23/2015 was reviewed. The IVC hold indicated in part, " Application is hereby made for the INVOLUNTARY EMERGENCY ADMISSION of the above (patient#1) named person...for the following reasons: That (he undersigned believes that the above named person is mentally ill, and because of this mental condition is likely to cause serious harm to self or others if not immediately hospitalized.. . . 1. The specific type of serious harm thought proba

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