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Based on medical record review, staff and physician interviews, and review of inquiry call documentation and policies, the facility failed to comply with 42 CFR 489.24. The facility failed to accept a transfer of an individual who required specialized capabilities (psychiatric services) from a referring hospital when they had the capacity to treat, for 1 of 20 sample records reviewed (#9). The findings were:

Refer to A2411 for details on the facility's failure to accept a transfer of patient #9 from a referring hospital who needed psychiatric services.

Based on medical record review, staff and physician interviews, and review of inquiry call documentation and policies, the facility failed to accept a transfer of an individual who required specialized capabilities (psychiatric services) from a referring hospital when they had the capacity to treat for 1 of 20 sample records reviewed (#9). The findings were:

1. Review of WBI's "Inquiry Call" documentation for patient #9 showed the referral source was hospital #1 [critical access hospital with an emergency room] and the call came in on 7/1/24 at 7:41 PM. The presenting problems listed included "SI/HI [suicidal ideation/homicidal ideation]", and "381" [3-81, emergency detention]. Review of the 3-81 form showed the reason for the emergency detention was "suicidal and homicidal ideation, psychiatry recommended in-patient treatment." Review of the intake worksheet (completed by an intake nurse from the facility) dated 7/1/24 at 8:18 PM showed the patient was a 13 year old who had been staying at a youth crisis center. The patient answered yes on all of the suicidal ideation screening questions and after an argument with his/her mother, had an increase in suicidal ideation. The plan was to cut his/her wrist or neck and bleed out. The high risk behaviors were listed as suicidal ideation with plans and homicidal ideation towards the mother. The intake also stated the patient stole money from his/her mother and she was pressing charges. The diagnoses listed on the intake form were depression, anxiety, fetal alcohol syndrome, and PTSD. The following concerns were identified:
a. Review of the WBI inquiry call sheet [documentation kept by WBI to show referrals received by telephone] showed the physician decision was done by psychiatrist #1 [psychiatrist at WBI] on 7/1/24 at 9:41 PM and the decision was "denied- feels its conduct d/o [disorder] needs to go to JDC [juvenile detention center]."
b. Further documentation showed at 10 PM the emergency room (ER) physician from hospital #1 called and was upset and wanted to talk to psychiatrist #1. The intake nurse texted the contact information to psychiatrist #1.
c. Review of a typed "inquiry call notes update" showed the ER physician called and spoke to psychiatrist #1. Psychiatrist #1 then spoke to the patient's mother. Psychiatrist #1 told facility staff they were not taking the patient. The facility staff received a call from the ER physician asking to speak to the CEO. He stated the patient was on a hold, was acutely SI and HI and was not safe to send home. The facility staff called the admissions director and he said it could be re-visited in the morning.

2. Review of the emergency room record from hospital #1 showed the following:
a. Patient #9 was seen by ER physician #1 on 7/1/24 at 3:27 PM. The ED physician note showed the patient was suicidal and stated s/he would either cut their wrists or neck and let himself/herself bleed out. The patient had been staying at a crisis center since s/he reportedly had been stealing from the mother and she was pressing charges. Per the crisis center, s/he said that s/he wanted to stab his/her mother to death. The note further stated the ER physician spoke to the mother and she stated she didn't feel the patient would be safe at home, and she didn't feel safe with him/her at home. The ED physician consulted telepsychiatry.
b. Review of the psychiatric evaluation dated 7/1/24 showed the patient was in the ER because "I said I was going to kill myself." The mental status exam showed "suicidal ideation with plan, endorses homicidal ideation without target." The patient had a history of fighting in school, multiple recent acts of violence towards animals, and threatened to kill his/her mother. The assessment/impression was documented as "...[S/he] is continuing to endorse suicidal ideation and endorsing specific thoughts of cutting [his/her] wrists to hill [himself/herself]...Although [s/he] denied intent to me given [his/her] history of aggressive behaviors and [his/her] current acute stressors, in my opinion this patient is at acutely elevated risk for causing serious bodily harm to [himself/herself] and others at this time. Psychiatric hospitalization is recommended." The diagnoses were listed as major depressive disorder, recurrent, severe, PTSD, and r/o [rule out] conduct disorder. The recommendation was for inpatient behavioral health on an involuntary basis.
c. Review of the ER physician note showed "WBI contacted for bed availability, they will call back."
d. Review of a progress note dated 7/1/24 at 11:20 PM showed staff from WBI called the ER to let them know that "...the Psychologist denied taking the patient due to the fact that he felt that [s/he] needed to due [sic] [his/her] punishment for stealing. She told me that they had availability, but he denied."
e. Review of the ER physician note showed on 7/1/24 at 11:20 PM he documented that the WBI psychiatrist refused the patient. He placed a call into the psychiatrist. At 11:30 PM the ER physician documented he spoke to the psychiatrist who advised him this was more of a behavioral issue, that they were more difficult to treat, and that the patient was going to be a nightmare disposition. "I advised him again that the patient was acutely suicidal and homicidal." The psychiatrist agreed to speak to the mother. At 11:50 PM the psychiatrist called back and stated he was not going to accept the patient because this was not an acute issue, and because the mother told him that the patient had beaten up other children in the past. "I again advised him that the patient was acutely suicidal, was on an emergency petition, that [s/he] couldn't go back to the crisis center, and [s/he] couldn't go home, and asked him what I was supposed to do with the patient, as we do not have the capacity to care for [him/her] here."
f. Review of the ER physician note showed on 7/2/24 at 12:10 AM he called WBI and asked to have the administrator on call contact him. At 12:15 AM he spoke with WBI staff again and was told they suggested that the ER hold the patient overnight and they would have their administration sort this out in the morning.
g. Further review of the ER physician note showed the facility contacted six other facilities before finally having a seventh facility accept the patient on 7/2/24 at 2:27 PM. That accepting facility was located out of state.
h. Review of EMS documentation showed the patient was transported to the facility out of state on a ground ambulance. The patient left the ER on 7/2/24 at 4:03 PM and arrived at the recipient facility out of state on 7/2/24 at 8:41 PM.

3. Further review of the inquiry call documentation from WBI showed on 7/2/24 the director of nursing (DON) from hospital #1 (the critical access hospital that wanted to transfer patient #9) called at 9 AM and requested to speak to an administrator in regards to patient #9 being denied. A note dated 7/2/24 at 11:08 AM by the admissions director showed he called the DON. The DON voiced concerns about WBI not accepting the patient. She stated their hospital [hospital #1, the critical access hospital] was not the correct placement for him/her. The admissions director stated he planned to have the case re-reviewed. A note dated 7/2/24 at 4 PM revealed the case was reviewed with another psychiatrist who accepted the patient and admission orders were received. Another note dated 7/2/24 at 4:05 PM revealed the DON at the hospital was contacted who stated the patient was accepted to a facility out of state and they were no longer seeking WBI services.

4. On 8/30/24 at 9:23 AM ER physician #1 was interviewed. He stated patient #9 was brought in by police to their hospital (hospital #1). He stated the mother couldn't control him/her and s/he was making suicidal threats. He stated the patient was not suitable to be discharged and the hospital didn't have the capability to handle psychiatric issues. WBI was contacted and they called back and stated the psychiatrist denied the transfer. The ER physician stated the psychiatrist refused the patient before even talking to him. He stated he called the psychiatrist after finding out he denied the transfer. He stated the psychiatrist told him the patient needed long term care and would be a "disposition nightmare." He stated the psychiatrist gave him a number to a facility out of state, but when he called, it was not acute care. He stated WBI denied the transfer even though they had beds. He stated a telepsych evaluation was done in the ER and the recommendation was for inpatient psychiatric care. He stated WBI accepted the patient the following day about 4 PM, but by then the patient was gone. He stated the patient was transferred to an acute psychiatric facility out of state.


5. During an interview on 8/29/24 at 9:31 AM the compliance officer for hospital #1 stated the psychiatric evaluation that was done on patient #9 showed s/he needed inpatient psychiatric services. She stated the medical director at WBI stated it was more of a "discipline problem" than a psychiatric issue and the patient needed jail. The patient ended up going to a psychiatric facility out of state.

6. On 8/29/24 at 10:29 AM psychiatrist #1 (for WBI, also the medical director) was interviewed. He stated he spoke to the ER physician twice and spoke to the patient's mother. He stated he thought it sounded more like conduct disorder and the patient didn't meet acute criteria. He also stated the patient wouldn't be appropriate "due to the current milieu here." He stated he explained all of that to the ER physician who then said it seemed like an EMTALA violation. He stated he was not going to change his opinion. He stated the next day another psychiatrist reviewed the case and decided to take the patient, but the patient already found another place out of state. When asked about the findings and recommendation from the psychiatric evaluation done at the ER, he stated he thought the evaluation was not accurate. He stated he would argue with the diagnosis of major depression and stated it seemed like conduct disorder. When asked if he evaluated the patient, he stated his decision was based on his discussions with the ER physician and mother and information that was relayed to him from the intake staff. He did state "we have conduct disorder here, so we don't exclude" but stated they needed to look at the milieu.

7. During an interview on 8/29/24 at 10:48 AM the admissions director stated he got involved when the DON called on 7/2/24. He told her they would re-review the case and had another psychiatrist review it. He stated that psychiatrist gave orders to admit at 4 PM but by then the hospital had found another facility out of state. He stated the denial by psychiatrist #1 was not due to lack of beds but because he felt the patient wasn't appropriate. He did state that the facility accepts patients with similar complaints. He stated the facility had the capability to handle suicidal ideations and behavioral problems..."that's what we do."

8. Review of the facility's "Overview of Services" policy (undated) showed "...The Youth Acute Inpatient Program is designed to accommodate and treat individuals, between the ages of five (5) and seventeen (17) years, with a variety of emotional, cognitive and behavioral difficulties." Further, "...Admission Criteria: Youth Acute Inpatient Psychiatric Hospitalization: Severity of Illness (SI): An adolescent may be considered appropriate for admission to an acute inpatient program if ONE (1) of the following Severity of Illness criteria are met: 1. Patient makes direct threats or a clear and reasonable inference of serious harm to self, or had made a suicide attempt that is serious by degree of intent and impulsivity. 2. Patient demonstrates violent, unpredictable or uncontrolled behavior which represents potential serious harm to body or property of others or there is evidence for a clear and reasonable inference of serious harm to others. 3. Patient requires a diagnostic assessment or treatment that are not safe on an outpatient basis, such as medication management. 4. Patient requires a diagnostic assessment or treatment that are not safe on an outpatient basis, such as medication management [repeat of #3]. 5. Disordered/bizarre behavior or psychomotor agitation or retardation interferes with the activities of daily living to such a degree that the patient cannot function at a lower level of care. 6. There is severe, sustained, and pervasive inability to attend to age-appropriate responsibilities and/or severe deterioration of family and school functioning and no other level of care would be intensive enough to evaluate and treat the disorder.

9. The sample included 20 inquiry calls. Review of the inquiry call documentation showed the following adolescent patients, with similar presenting problems to patient #9, were approved for admission:
a. Patient #3 was 16 years old and was admitted on 7/22/24. The presenting problem was thoughts of self harm and thoughts of harming others. The patient was acting out sexually, physically and verbally and had attacked his/her mother and hit his/her niece.
b. Patient #4 was 15 years old and was admitted on 7/14/24. The presenting problem was suicidal ideation on the way to the detention center (for elopement).
c. Patient #5 was 17 years old and was admitted on 7/3/24. The presenting problem was history of bipolar and voices telling him/her to kill himself/herself.
d. Patient #6 was 15 years old and was admitted on 7/23/24. The presenting problems included: on a 3-81 hold and was a danger to others, property destruction, animal cruelty, homicidal threats, and conduct disorder.
e. Patient #10 was 13 years old and the presenting problems included: SI, HI, was violent with sister and broke TV. The patient was approved on 8/2/24, but there were no beds available.
f. Patient #14 was 14 year old and had suicidal ideation. The patient was approved on 8/1/24 but there were not beds available.