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Based on observation and review of: the hospital's Crisis Intervention Services-Log Sheets(CISLS), Unit 2SB Acuity Report Sheets (2SBARS), interviews with Risk Management Staff, interview of the MedStar Franklin Square Medical Center Psychiatric Service Director and review of "referring hospitals" patient medical records requesting inpatient psychiatric treatment, it was determined that MedStar Franklin Square Medical Center had available beds and capacity to accept patients for inpatient psychiatric admissions but declined to admit 8 of 40 patients reviewed.

On May 15, 2014 the CMS Regional Office received a complaint allegation that Med Star Franklin Square Medical Center failed to accept certain patients for admission into the Behavioral Health Units (2SB and CAP) based on the hospital ' s previous knowledge of the patients ' histories and behaviors and at the mandate of the chief psychiatrist and the nurse manager of the facility. It was alleged that, essentially the hospital used a list of undesirable patients to deny admission rather than the patient ' s need for services as the criteria for admission. While the list of patients was not located, the surveyors found that the hospital had multiple logs and forms to document the process for identifying patients selected for admission, denial, and transfer. The Crisis Intervention Service log also had a column identifying the patient ' s insurance status, which is prohibited under EMTALA. While no consistent correlation was found between the patient ' s insurance status and admission, the surveyors found that the hospital failed to admit patients (in particular transfer patients from other hospitals requiring inpatient behavioral health care) when the hospital had the capacity and the capability to accept these patients.


Despite documentation on the 2SB Unit Acuity Forms which indicated that the hospital had capacity and capability to accept aggressive or assaultive patients, the hospital systematically failed to accept transfers and admissions from other hospitals ' Emergency Departments without documented evidence that the MedStar Franklin Square Medical Center could not serve the patient. The log sheets provided extremely limited information about the various reasons for denial. For example, in some cases, the hospital log sheets documented the reason for denial as simply, " declined for aggression. " The hospital historically has served individuals with aggression and other challenging behaviors in its behavioral health units.


It is also noted that during the interview of the Psychiatric Service Director [DR.M] on 05/27/2014, the Director shared in the interview, that many patients present to the hospital with " personality disorders that re not amenable to fixing, nobody wants them, we just don ' t treat them or transfer them; police bring them in and dump them in the ER. " The Director further stated that, " No patient discharged from CIS has killed themselves or others (in 30 years), and that she stands on that. " This is further evidence of the systemic practice of non-acceptance of preselected patients in violation of EMTALA requirements. This deficient practice constitutes an Immediate Jeopardy and a threat to the health and safety of individuals who present to the emergency department or request transfer from another hospital and request treatment.

The hospital uses an Acuity Ranking Scale for the Acuity Report that rates the 2SB ( Behavioral Health) Unit's acuity level during a designated time . The rating ranges between a (1) low acuity and up to a (5) for very acute. This tool also tracks bed availability for both the Adult and Child/Adolescent units. This tool is used for purposes of maintaining patient and staff safety through assessing the number of patients on the unit, the patients' care needs, and the number of staff required to achieve that goal.


The surveyors reviewed a selection of closed and open Emergency Department records and reviewed logs of patients who were refused transfer from another hospital for admission into MedStar Franklin Square Medical Center inpatient psychiatric units. The following patients were in other hospitals emergency departments where it was determined that the patient required inpatient psychiatric services. These patients were refused transfer and admission to the hospital when the hospital had both capacity and capability.


Patient #12 is a 34 year old female referred from an OSH (outside hospital) to MFSMC MedStar Franklin Square Medical Center) at from 1000-1050 (10:00-10:50 AM) on April 18, 2014 for direct admit to the inpatient psychiatric adult unit . The patient per the CISLS (Crisis Intervention Services Log Sheet) was declined due to "methadone pregnancy" as documented on the CISLS. Review of the 2SB acuity report sheet revealed 5 available general beds between the hours of 7 am-7pm and at 7:35pm with available beds for 2 males and 3 females. From 7am-7pm the report indicates the unit as no quiet room, restraints/seclusion, zoned patients, manic patients, on eyesight, 1:1 with 3 psychotic patients and 1 alcohol withdrawal. By 7:35pm the number of psychotic patients increased to 9 and there were 2 manic patients. The patient was under consideration for a female bed between 10:00-10:50 AM when 3 female beds were available and the acuity was rated as " 3". Based on review of the patient's medical records at the OSH, the reason given by MFSMC for the declining the patient's admission was due to not having a bed. As per the information from the acuity sheets there were 3 female beds available but the patient was declined per the note of 4/18/14 at 6:07pm. The patient was accepted by another OSH on 4/19/14 at 3:32 PM.


Patient #13 is a 38 year old male referred from an OSH to MFSMC on April 29, 2014 between 8:15-8:45 PM for direct admit to the inpatient psychiatric unit. The patient presented with moderate risk to harm self. Per the CISLS log at MFSMC, the patient was declined because patient was on multiple narcotics for back pain. The 2SB acuity report sheet at 7:00pm revealed that there were 4 available beds (2 male and 2 female). Further the unit acuity indicated that there were 3 quiet rooms in use, 9 psychotic patients, 4 manic patients, and 2 patients in withdrawal and an acuity range from 3 to 5. The medical record from the OSH revealed the patient was declined transfer and admission . The note stated MFSMC advised that the patient will not receive any of his pain medication at their facility and will only receive Tylenol. The hospital had the bed availability for patient #13.


Patient #14 is 34 year old male referred from an OSH on May 5, 2014 between from 1:47-2:30 AM for direct admit to the inpatient psychiatric unit. The patient was brought in on EP ( Emergency Petition) due to positive for voices and threatening others. Per the CISLS log at MFSMC for 5/5/14 , the rationale for declining transfer and admission to the was "agitated." On 5/4/14 at 7:30 PM, the 2SB acuity report sheet indicates that were were 4 available beds and no quiet room use, zoned patients, on-eyesight patients, no 1:1 patients, 5 psychotic patients, 1 manic patient and 3 acute alcohol withdrawal with unit acuity of 2. The hospital declined the patient due to his agitation when there was bed availability .


Patient #15 is a 52 year old male referred from and OSH on April 5, 2014 between 5:00-5:05 PM. for direct admit to the inpatient psychiatric unit. The patient has a history of depression with worsening depression. Per the CISLS, it was revealed that the patient declined by MFSMC for violence but the medical record from the OSH revealed the patient was denied due to unit acuity. In fact the 2SB acuity report sheet at 7:35 AM revealed a unit census of 18 with 3 psychotic patients, 2 total care patients and 4 patients with alcohol withdrawal. The unit acuity was slightly higher than medium " 3". By 7:30 PM , the unit census was 22 with 2 quiet rooms in use, 2 psychotic patients, 2 manic patients and 1 alcohol withdrawal. There were 7 beds available at the time of the denial 2 hours before the 7:30 PM acuity report.


Patient #16 is a 75 year old female referred from and OSH on April 9, 2014 between 12:00-2:20 PM for direct admit to the inpatient psychiatric unit. Per the note written by the OSH no beds were available at MFSMC but the MFSMC's 2SB acuity report sheet revealed at 7:30 AM and PM unit a census of 20 beds with both available male and female beds with unit acuity medium 3. Further it indicated that there were 2-3 psychotic patients and 2 manic patients, no total care patients, no acute alcohol withdrawal, no zoned for safety, no eye-sight, and no 1:1 patients but 2 quiet rooms were in use. The patient was declined admission due to no bed availability but the acuity report sheets reveal beds were actually available with medium unit acuity.


Patient #38 was a 46 year old male who presented to an outside hospital's Emergency Department (ED) ambulatory on 03/16/14 at 03:24AM with a history of Bi-polar Disorder, anxiety, depression and suicide ideation (without a plan), and not taking his psychiatric medications for 6-7 days. The patient had been attempting self medicating with the use of cocaine. The patient was assessed by nursing staff at 05:23 as alert and oriented times three, cooperative, and well groomed. The patient was referred to MedStar Franklin Square Medical Center (MFSMC) and review of the CISLS for 03/16/14, it was noted that between 08:40-09:50AM the patient was declined admission to the Inpatient Psychiatric Unit as noted by, " Declined by Dr. M acuity " . A review of the 2SBARS on 03/16/14 between 7AM-7PM revealed that the unit ' s acuity was rated as a (3) medium with the following: 22 patients with (1) to come, number of beds:(1) open private, (1) open room with 2 beds, (3) female beds; (1) new quiet room, (3) psychotic patients, (1) manic patient, (2) patients in acute ETOH(alcohol) withdrawal, (1) on eyesight, ( 0) zoned for safety, and (0) for 1:1. Based on the acuity of unit which was medium and the bed availability the hospital had the capacity to accept the patient but declined. The outside hospital had no available beds and the patient was discharged on 03/16/14 at 19:07 to another outside hospital for inpatient psychiatric care.

Patient #39 was a 27 years old male with a history of schizophrenia and medication non-compliance. The patient was brought into an outside hospital ' s ED by the police on 03/15/14 at 11:49AM. The patient was actually " emergency petitioned " by a family member. The patient was noted as " aggressive " with the officers. The patient was treated in the ED with medication twice and required the use of restraints at some point in the care. The outside hospital staff worked on transferring the patient to multiple local locations for care but there were no available beds. A note entered in the patient ' s medical record by the outside hospital nursing staff on 03/16/14 at 12:18AM reads, " Pt. was denied at MFSMC because the " patient does not fit their acuity ." A review of the hospital's 2SBARS for 03/15/14 at 19:30 (7:30PM) revealed the unit had a census of 21 patients, with (2) of the patients being under the direction Kaiser, (5) general available beds of which (3) were female beds, (1) quiet room(zoned for eyesight), (2) psychotic patients, (2) manic patients, (1) patient on eyesight, and (0) patients requiring total care , needing acute alcohol withdrawal, or in need of 1: 1 staff supervision. A review of the CISLS dated 03/15/14 between 1900-2044 (7:00PM-8:44PM). noted that the patient was declined by the MFSMC psychiatrist for acuity reasons. Although the patient was denied based on acuity, the hospital ' s 2SBARS form reflected that the acuity level on this date was a 3(medium) with a bed availability of 8 ( 3 out of the 8 were noted as female beds).


Patient #40 was 17 years old, who presented to the ED of an outside hospital with a parent on 03/12/14 early morning. The reason the patient was brought to the ED as noted by the Risk Manager was because the patient had been found at school with a piece of glass and it appeared that the intention of the patient was to cut a wrist. The patient's suicidal ideation and risk for self injurious behavior prompted referrals to other psychiatric facilities. A review of the MedStar-Franklin Square Hospital (MFSMC) CISLS Sheet for 03/12/14 indicated " Declined" during the time frame of 16:45-18:50 (4:45-6:50PM) with no other explanation. The CAPS (Children, Adolescent Psychiatric Services) Acuity Report Sheet for 03/12/14 at 20:00(8PM), indicated the census was 8, with 3 available beds that included both male and female beds. The number of aggressive and self injurious patients was noted as " potential " with 1 new patient in last 24 hours and 0 patients in behavior modification, zoned for safety, on eyesight, or need of 1:1 supervision. At 07:23 the referring outside hospital staff noted that "M" at MFSMC indicated " possibly one bed available, but may be used for someone waiting for a consult from their psychiatrist. If the patient is referred, the packet would not be reviewed until sometime the next shift. ". The patient was transferred to another outside hospital on 03/13/14 for care.


As evidenced in the above cases the hospital failed to accept a patient for transfer from referring hospitals for the provision of specialized psychiatric care when it had the capacity and capability to do so.