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Based on review of policies/procedures, documentation, and staff interviews, the hospital, a tertiary center, failed to accept an appropriate transfer of a patient in a psychiatric emergency medical condition, that Hospital A did not have the capabilities or capacity to care for (Patient #1) out of 50 medical records selected for review from April to June 2011.

Failure to accept appropriate transfers within the capabilities of the hospital resulted in the delay of stabilizing treatment for Patient #1.

Findings include:

1. Review of the policy, "The Emergency Medical Treatment and Active Labor Act (EMTALA) As Amended," revised date December 5, 2007, revealed in part ". . . Acceptance of Transfers from Outside Facilities: Any physician with clinical privileges at the UIHC [University of Iowa Hospitals & Clinics] must be made by the on-call faculty physician of the service to which admission is sought. . . ."

The policy also revealed "Services of Consulting (on-call) Physicians: . . . Requests from a sending facility located within the boundaries of the United States to accept a transfer because the sending facility lacks specialized service(s) available at the UIHC will not be denied, unless the UIHC does not have capacity to accept another patient. A determination that a speciality service does not have the capacity to accept the transfer may be declared only by the on-call faculty physician of the specialty service unit for which admission is sought. If such a denial becomes necessary, the on-call faculty of the specialty service shall cooperate with the sending facility in seeking appropriate placement. . . ."

2. Review of the policy, "Patient Transfer Requests," revised date April 15, 2009, revealed in part ". . . Purpose: To maintain a consistent and efficient method for accepting emergent and non-emergent patient transfers to UIHC. . . . Criteria for Transfer: Emergency Medical Condition - patient has an emergent medical condition that has not been stabilized and is in an outside hospital or emergency department where they are unable to treat the patient. . . . Prioritization of Transfer Patients by category: . . . Category Three - Psychiatric patients without acute medical conditions. . . ."

3. During a telephone interview on 6/20/11 at 3:15 PM, Emergency Department (ED) Physician B, at Hospital A, reported contacting Physician A (the on call psychiatric physician at UIHC), to arrange the transfer of Patient #1, on 5/6/11 at approximately 5:45 PM. Physician A stated he needed more information regarding Patient # 1 and failed to accept the transfer request for Patient #1 at that time. Physician B stated Physician A called him back approximately 1 hour later and failed to accept the transfer request for Patient #1.

Physician B stated Hospital A then proceeded to contact a second hospital to arrange transfer of Patient #1 and successfully arranged the transfer of Patient #1 to Hospital B.

4. During an interview on 6/20/11 at 12:05 PM, Physician A confirmed he was on call 5/6/11. Physician A confirmed Hospital A had contacted him on 5/6/11 and requested acceptance of transfer for Patient #1 who required further stabilization beyond Hospital A's capabilities which included in-patient psychiatric treatment. Physician A stated that he needed more information regarding Patient #1 and failed to accept the patient.

5. Review of Hospital A's medical record revealed that after discussing the transfer with Physician A at UIHC and not receiving acceptance, Physician B contacted a second hospital and transferred Patient #1 to Hospital B (a second hospital) where further care could be provided to treat his emergency. Refer to tag 2411 for further details.

Based on document review and staff interview, the hospital a tertiary care center, failed to accept an appropriate transfer of a patient in a psychiatric emergency medical condition, that Hospital A did not have the capabilities or capacity to care for (Patient #1) out of 50 medical records selected for review from April to June 2011.

Failure to accept a patient in an unstable emergency medical condition resulted in the delay of stabilizing treatment for Patient #1.

Findings and hospital capabilities include:

1. Review of UIHC (University of Iowa Hospitals & Clinics) on-call scheduled for 5/6/11 confirmed that Physician A was the on-call physician for psychiatry.

2. Review of the census sheet for Adult Psychology at UIHC, dated 5/6/11 and timed 5:45 PM, revealed an adult psychiatric bed was available. During an interview on 6/21/11 at 8:15 AM, Staff A confirmed the availability of an adult psychiatric bed on 5/6/11 at 5:45 PM.

3. Review of documentation revealed an average of 136 adult patients admitted to inpatient psychiatric units at UIHC per month for the past 6 months (December 2010 to May 2011).

4. Review of documentation revealed an average of 11 adult patients transferred from an outside acute hospital to inpatient psychiatric units at UIHC per month for the past 6 months (December 2010 to May 2011).

5. Review of Scope of Services for the Department of Psychiatry revealed in part, " . . . The Department for Psychiatry within the UIHC structure provides a continuum of behavioral health services designed to meet the needs of children, adolescents, adult and older adults. Services include the following: Inpatient treatment for general adult patients, older adults, children, and adolescents. . . ."

6. Review of policy "Admission, Exclusion, Continued Stay, and Discharge Guidelines University of Iowa Hospitals and Clinics Department of Psychiatry" revealed in part ". . . Adult Admission Criteria: Inpatient psychiatric treatment at the University of Iowa Hospitals and Clinics (UIHC) is reserved for patients whose symptoms are acute and severe enough to require 24-hour-per-day care and supervision. . . B. Danger to self/others: Patient poses an actual or imminent danger to self/others due to recent to manifestations of an active, acute psychiatric disorder. Manifestations of an acute psychiatric disorder can include but may not be limited to: suicide attempt, suicidal ideation with plan, serious self-mutilation and/or reckless endangerment, or serious assaultive behavior towards others or expressed intention to engage therein. This danger to self/others cannot be managed in an outpatient or less restrictive setting and requires a locked inpatient unit as the least restrictive setting to keep the patient and others safe. . . ."

7. During an interview on 6/21/11 at 10:15 AM, Staff B, Administrator Department of Psychiatry, acknowledged UIHC psychiatry department has served children/adult patients with intellectual disabilities (mentally retarded) as long as they have a psychiatric diagnosis and suicidal/homicidal ideation is identified as a need for hospitalization. Staff B stated a resident physician could accept a patient for evaluation for possible admission from an outside hospital.

8. Review of Physician A's file showed he had a current contract as a House Staff Member as a Resident 1 in Family Practice/Psychiatry and obligated to perform duties in compliance with the Bylaws, Rules and Regulations of UIHC.

9. Telephone interview with Emergency Department (ED) Physician B, at Hospital A (transferring hospital) on 6/20/11 at 3:15 PM confirmed Physician B had contacted the on call psychiatric physician at UIHC (Physician A) on 5/6/11 at approximately 5:45 PM requesting acceptance of an unstable emergency room patient (Patient #1) who needed inpatient psychiatric services. Physician B confirmed Hospital A did not have inpatient psychiatric services and that he contacted Physician A because of inpatient psychiatric services available at UIHC. Physician A stated he needed more information regarding Patient # 1 and failed to accept the transfer request for Patient #1 at that time. Physician B stated Physician A called him back approximately 1 hour later and failed to accept the transfer request for Patient #1.

Physician B stated Hospital A then proceeded to contact a second hospital to arrange transfer of Patient #1 and successfully arranged the transfer of Patient #1 to Hospital B.

10. During an interview on 6/20/11 at 12:05 PM, Physician A confirmed he was on call 5/6/11. Physician A confirmed Hospital A had contacted him on 5/6/11 and requested acceptance of transfer for Patient #1 who required further stabilization beyond Hospital A's capabilities which included in-patient psychiatric treatment. Physician A stated that he needed more information regarding Patient #1 and failed to accept the transfer of the patient.

Based on review of policies/procedures, documentation, and staff interviews, the hospital, a tertiary center, failed to accept an appropriate transfer of a patient in a psychiatric emergency medical condition, that Hospital A did not have the capabilities or capacity to care for (Patient #1) out of 50 medical records selected for review from April to June 2011.

Failure to accept appropriate transfers within the capabilities of the hospital resulted in the delay of stabilizing treatment for Patient #1.

Findings include:

1. Review of the policy, "The Emergency Medical Treatment and Active Labor Act (EMTALA) As Amended," revised date December 5, 2007, revealed in part ". . . Acceptance of Transfers from Outside Facilities: Any physician with clinical privileges at the UIHC [University of Iowa Hospitals & Clinics] must be made by the on-call faculty physician of the service to which admission is sought. . . ."

The policy also revealed "Services of Consulting (on-call) Physicians: . . . Requests from a sending facility located within the boundaries of the United States to accept a transfer because the sending facility lacks specialized service(s) available at the UIHC will not be denied, unless the UIHC does not have capacity to accept another patient. A determination that a speciality service does not have the capacity to accept the transfer may be declared only by the on-call faculty physician of the specialty service unit for which admission is sought. If such a denial becomes necessary, the on-call faculty of the specialty service shall cooperate with the sending facility in seeking appropriate placement. . . ."

2. Review of the policy, "Patient Transfer Requests," revised date April 15, 2009, revealed in part ". . . Purpose: To maintain a consistent and efficient method for accepting emergent and non-emergent patient transfers to UIHC. . . . Criteria for Transfer: Emergency Medical Condition - patient has an emergent medical condition that has not been stabilized and is in an outside hospital or emergency department where they are unable to treat the patient. . . . Prioritization of Transfer Patients by category: . . . Category Three - Psychiatric patients without acute medical conditions. . . ."

3. During a telephone interview on 6/20/11 at 3:15 PM, Emergency Department (ED) Physician B, at Hospital A, reported contacting Physician A (the on call psychiatric physician at UIHC), to arrange the transfer of Patient #1, on 5/6/11 at approximately 5:45 PM. Physician A stated he needed more information regarding Patient # 1 and failed to accept the transfer request for Patient #1 at that time. Physician B stated Physician A called him back approximately 1 hour later and failed to accept the transfer request for Patient #1.

Physician B stated Hospital A then proceeded to contact a second hospital to arrange transfer of Patient #1 and successfully arranged the transfer of Patient #1 to Hospital B.

4. During an interview on 6/20/11 at 12:05 PM, Physician A confirmed he was on call 5/6/11. Physician A confirmed Hospital A had contacted him on 5/6/11 and requested acceptance of transfer for Patient #1 who required further stabilization beyond Hospital A's capabilities which included in-patient psychiatric treatment. Physician A stated that he needed more information regarding Patient #1 and failed to accept the patient.

5. Review of Hospital A's medical record revealed that after discussing the transfer with Physician A at UIHC and not receiving acceptance, Physician B contacted a second hospital and transferred Patient #1 to Hospital B (a second hospital) where further care could be provided to treat his emergency. Refer to tag 2411 for further details.

Based on document review and staff interview, the hospital a tertiary care center, failed to accept an appropriate transfer of a patient in a psychiatric emergency medical condition, that Hospital A did not have the capabilities or capacity to care for (Patient #1) out of 50 medical records selected for review from April to June 2011.

Failure to accept a patient in an unstable emergency medical condition resulted in the delay of stabilizing treatment for Patient #1.

Findings and hospital capabilities include:

1. Review of UIHC (University of Iowa Hospitals & Clinics) on-call scheduled for 5/6/11 confirmed that Physician A was the on-call physician for psychiatry.

2. Review of the census sheet for Adult Psychology at UIHC, dated 5/6/11 and timed 5:45 PM, revealed an adult psychiatric bed was available. During an interview on 6/21/11 at 8:15 AM, Staff A confirmed the availability of an adult psychiatric bed on 5/6/11 at 5:45 PM.

3. Review of documentation revealed an average of 136 adult patients admitted to inpatient psychiatric units at UIHC per month for the past 6 months (December 2010 to May 2011).

4. Review of documentation revealed an average of 11 adult patients transferred from an outside acute hospital to inpatient psychiatric units at UIHC per month for the past 6 months (December 2010 to May 2011).

5. Review of Scope of Services for the Department of Psychiatry revealed in part, " . . . The Department for Psychiatry within the UIHC structure provides a continuum of behavioral health services designed to meet the needs of children, adolescents, adult and older adults. Services include the following: Inpatient treatment for general adult patients, older adults, children, and adolescents. . . ."

6. Review of policy "Admission, Exclusion, Continued Stay, and Discharge Guidelines University of Iowa Hospitals and Clinics Department of Psychiatry" revealed in part ". . . Adult Admission Criteria: Inpatient psychiatric treatment at the University of Iowa Hospitals and Clinics (UIHC) is reserved for patients whose symptoms are acute and severe enough to require 24-hour-per-day care and supervision. . . B. Danger to self/others: Patient poses an actual or imminent danger to self/others due to recent to manifestations of an active, acute psychiatric disorder. Manifestations of an acute psychiatric disorder can include but may not be limited to: suicide attempt, suicidal ideation with plan, serious self-mutilation and/or reckless endangerment, or serious assaultive behavior towards others or expressed intention to engage therein. This danger to self/others cannot be managed in an outpatient or less restrictive setting and requires a locked inpatient unit as the least restrictive setting to keep the patient and others safe. . . ."

7. During an interview on 6/21/11 at 10:15 AM, Staff B, Administrator Department of Psychiatry, acknowledged UIHC psychiatry department has served children/adult patients with intellectual disabilities (mentally retarded) as long as they have a psychiatric diagnosis and suicidal/homicidal ideation is identified as a need for hospitalization. Staff B stated a resident physician could accept a patient for evaluation for possible admission from an outside hospital.

8. Review of Physician A's file showed he had a current contract as a House Staff Member as a Resident 1 in Family Practice/Psychiatry and obligated to perform duties in compliance with the Bylaws, Rules and Regulations of UIHC.

9. Telephone interview with Emergency Department (ED) Physician B, at Hospital A (transferring hospital) on 6/20/11 at 3:15 PM confirmed Physician B had contacted the on call psychiatric physician at UIHC (Physician A) on 5/6/11 at approximately 5:45 PM requesting acceptance of an unstable emergency room patient (Patient #1) who needed inpatient psychiatric services. Physician B confirmed Hospital A did not have inpatient psychiatric services and that he contacted Physician A because of inpatient psychiatric services available at UIHC. Physician A stated he needed more information regarding Patient # 1 and failed to accept the transfer request for Patient #1 at that time. Physician B stated Physician A called him back approximately 1 hour later and failed to accept the transfer request for Patient #1.

Physician B stated Hospital A then proceeded to contact a second hospital to arrange transfer of Patient #1 and successfully arranged the transfer of Patient #1 to Hospital B.

10. During an interview on 6/20/11 at 12:05 PM, Physician A confirmed he was on call 5/6/11. Physician A confirmed Hospital A had contacted him on 5/6/11 and requested acceptance of transfer for Patient #1 who required further stabilization beyond Hospital A's capabilities which included in-patient psychiatric treatment. Physician A stated that he needed more information regarding Patient #1 and failed to accept the transfer of the patient.