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Based on staff interview, clinical record, and administrative document review the hospital failed to comply with the provisions of CFR 489.24 when:

1. Five of twenty-six patients were diagnosed with psychiatric emergency conditions, placed on a 5150 72 hour hold (California Welfare and Institutions Code 5150 hold authorizes involuntary confinement for danger to self, danger to others or gravely disabled), and then transferred to a 23 hour crisis stabilization (CS) outpatient psychiatric clinic. One of the five patients was then transferred from the CS outpatient psychiatric clinic to an inpatient psychiatric hospital while still on the 5150 72 hour hold. (Refer to A2409)

2. The hospital failed to have written policies and procedures for on-call physicians in the event an on-call physician is not available due to unforeseen circumstances or were permitted to schedule elective surgeries during their on call timeframe. (Refer to A2404)

3. The emergency department log did not accurately reflect the Patient disposition for 3 of 26 Patients (Patients 1, 2, and 3) when the disposition was recorded as "Discharge/Dismiss to Home" instead of the patient's actual disposition of being transferred to the CS outpatient psychiatric clinic. (Refer to A2405)

These failures resulted in re-hospitalization for Patient 1 and the possible preventable re-hospitalization of other Patients and the potential of patient harm and injury during possible unnecessary transfer of patients; the potential for an on-call physician to not be available for a particular specialty; the potential for the hospital to not be able to accurately track the care and provide continuity of care to patients who come through the emergency department.

Based on staff interview and administrative document review the hospital failed to have written policies and procedures in place in the event an on-call physician is not available due to unforeseen circumstances or were permitted to schedule elective surgeries during their on call timeframe.

This failure resulted in the potential for an on-call physician to not be available for a particular specialty.

Findings:

On 10/7/15 at 2:03 p.m., during an interview, the Risk and Patient Safety Director (RPSD) stated the hospital did not have policies for on-call physician requirements.

On 10/7/15 at 3:40 p.m., during a concurrent record review and interview, The policy titled "PCS-ADM-012 On-Call after Hours Physician Availability" was reviewed. The purpose of the policy was "To ensure that inpatient units within Patient Care Services are aware of the physician and other health care professionals' availability to provide consultation and treatment for inpatients with medical needs." A request was then made for a policy specific to the physicians on-call for the emergency department. The Quality Nurse Consultant (QNC) stated that is the only policy the hospital has for on-call physicians. She stated she would continue looking for additional on-call policies.

On 10/8/15 at 10:18 a.m., during an interview, the Clinical Services Quality Director (CSQD) stated the physician on-call policies could not be found.

Based on staff interview and emergency department log review the hospital failed to ensure the emergency department log accurately reflected the Patient disposition for 3 of 26 Patients (Patients 1, 2, and 3) when the disposition was recorded as "Discharge/Dismiss to Home" instead of the patients actual disposition.

This failure resulted in not capturing information accurately for the purpose of process improvement.

Findings:

On 10/5/15 the clinical record for Patient 1 was reviewed. It indicated Patient 1 was transferred to an outpatient psychiatric clinic on 8/28/15. During a concurrent review of the Emergency log, the disposition listed for Patient 1 was Discharge/Dismiss to Home.

On 10/5/15 the clinical record for Patient 2 was reviewed. It indicated Patient 2 was transferred to an outpatient psychiatric clinic on 5/4/15. During a concurrent review of the Emergency log, the disposition listed for Patient 1 was Discharge/Dismiss to Home.

On 10/5/15 the clinical record for Patient 3 was reviewed. It indicated Patient 3 was transferred to an outpatient psychiatric clinic on 4/20/15. During a concurrent review of the Emergency log, the disposition listed for Patient 1 was Discharge/Dismiss to Home.

On 10/6/15 at 2:00 p.m., during an interview, the Emergency Department Director (DED) stated the Registered Nurses enter the disposition but the clerks can also enter the disposition. The clerks are the last ones to enter information into the system.

On 10/6/15 at 2:50 p.m., during an interview with the DED and the Emergency Department Support Supervisor (EDSS), the EDSS stated it could be an error. The DED stated the hospital currently receives a regional report from an analyst at a sister hospital but he doesn't know what flags it. The report was developed in May or June.

Based on staff interview, clinical record and administrative document review the hospital failed to ensure 5 of 26 sampled patients (Patients 1 through 5), who were placed on a 5150 72 hour hold (California Welfare and Institutions Code 5150 hold authorizes involuntary confinement for danger to self, danger to others or gravely disabled), had an appropriate transfer when they were transferred to a Crisis Stabilization (CS) outpatient psychiatric clinic that did not have the capability to treat them beyond 23 hours and 59 minutes. This resulted in Patient 1 having to be transferred from the outpatient clinic to an inpatient psychiatric hospital after 24 hours.

These failures resulted in patients being transferred to a non-hospital setting and the potential for delay in stabilizing care if they are required to be transferred to an inpatient psychiatric hospital after 24 hours.

Findings:

On 10/6/15 at 9:50 a.m., an interview was conducted with the Director of the Emergency Department (DED) to determine the flow within the emergency department (ED) for patients with mental health symptoms. The Emergency Department Director (DED) stated mental health patients are initially triaged (a process of assigning degrees of urgency to wounded or ill patients) by the triage nurse. If there is a concern the patient may be a danger to themselves or others, the charge nurse is notified and the patient is taken back to a room. The medical doctor is notified of the patient being a possible danger to self or others (DTS/DTO). Security is notified and items of potential hazard are removed from the patient and the room. The patients belongings are secured. The medical doctor conducts a medical screening exam (MSE) and writes necessary orders to rule out medical causes of the patients symptoms. In the event the physician performing the MSE finds no medical reason for the psychiatric symptoms, the patient is medically cleared. The medical doctor writes an order for a mental health assessment. The mental health providers assess the patients to determine whether the patient meets the criteria for a 5150 72 hour hold. In the event the mental health assessment results in a 5150 72 hour hold, the patient information is faxed to the hospitals psychiatric call center for placement. The placement is based on the information the call center receives from the mental health provider. The DED was asked if he was involved in the creation of the process to transfer psychiatric patients to the CS outpatient psychiatric clinic. The DED stated he was not involved in the discussions related to contracting with the CS outpatient psychiatric clinic to receive the hospitals psychiatric patients and did not know if EMTALA ramifications were discussed during the contract approval process. He stated he believed the Behavioral Health providers and outside (the hospital organization's Regional staff) administrative staff who deal with contracts were involved.

On 10/7/15 at 10:03 a.m., during an interview, the Regional Director for Inpatient Psychiatric Continuing Care (RDIPC) stated the outpatient psychiatric clinic was a "Crisis Stabilization Unit." He volunteered that he called the psychiatric call center and got the following numbers: 107 patients were sent to the outpatient psychiatric center since the hospital started using the service. Of those 107 patients, 48 were then required to be transferred from the CS outpatient clinic to an inpatient psychiatric hospital. He said the 48 patients transferred were hospital members only since they would not have any idea how many non-members were transferred to an inpatient psychiatric hospital. He stated the mental health clinicians were trained on when to use the various mental health options. He stated he was part of the group responsible for developing the strategy to use the CS outpatient psychiatric clinic but did not participate in developing the contract. He did not know if EMTALA ramifications were discussed. The documentation for the 48 patients transferred to the outpatient psychiatric clinic and then to an inpatient psychiatric hospital were requested from the Clinical Quality Services Director (CSQD) on 10/7/15 and on 10/8/15 but were not received.

Patient 1's clinical record indicated he arrived by ambulance to the Emergency Department (ED) at 7:53 p.m. on 8/27/15. The initial presenting complaint was listed as "Assault and Battery" and he was triaged as Acuity "2 Emergent." He received a medical screening exam by a physician at 8:23 p.m. and at 10:11 p.m. a psychological assessment was done. Patient 1 was medically cleared at 9:22 p.m. The psychological assessment recommendations for level of care indicated "Inpatient psychiatric care." At 11:15 p.m. Patient 1 was placed on a 5150 72 hour hold. The "Physician Assessment and Certification - Patient Transfer Under EMTALA/COBRA" indicated on the line item titled "Receiving Hospital" that the patient was transferred at 1:04 a.m. on 8/28/15 to the CS outpatient psychiatric clinic. The reason for transfer indicated "5150." Patient 1 was transferred to an inpatient psychiatric hospital on 8/29/15 at 8:56 a.m. and placed on a 5250 hold.

Patient 2's clinical record indicated he was brought in by ambulance at 3:11 p.m. on 5/4/15. He was triaged as an Acuity of "2 Emergent." He was on a 5150 hold for danger to self and others (DTS/DTO). He was placed on a 5150 by a clinic associated with the hospital's Health Maintenance Organization but not a licensed outpatient service of the hospital. A Psychological assessment was done at the clinic but not in the hospital's ED. The psychological assessment was not in the hospital medical record reviewed. The assessment was requested and received from the clinic's medical record. The clinic's psychological assessment treatment plan indicated it called for a reassessment for appropriateness of transfer to a residential treatment center. The "Physician Assessment and Certification - Patient Transfer Under EMTALA/COBRA" indicated on the line item titled "Receiving Hospital" that the patient was transferred to the outpatient psychiatric clinic on 5/4/15 at 11:45 p.m. The reason for transfer indicated "5150."

On 10/6/15 at 2:00 p.m., during an interview, when asked about the Patient being transferred to the CS outpatient psychiatric clinic prior to a a psychological assessment being done, the DED stated they wouldn't call the on-call mental health providers to come to the ED to re-evaluate the patient. He stated he didn't know if this process was in a policy but that it was the hospital's practice. Since the patient was on a 5150 72 hour hold the DED was asked if there was a policy for how often an assessment would be done to determine continuing need for the hold. He stated if the hospital can't find placement after 24 hours then the mental health providers would come and reevaluate the patient. When asked if there was a policy related to the timing of the assessments he stated it has been a verbal agreement and he has never seen a policy specifically addressing this issue.

Patient 3's clinical record indicated he was brought by ambulance to the ED on 4/20/15 at midnight and was triaged as an acuity of "2 Emergent." A medical screening exam was conducted at 12:58 a.m. and the patient was medically cleared. At 11:19 a.m. a psychological assessment was conducted. A 5150 was placed for DTS at 11:15 a.m.on 4/20/15. The psychological assessment indicated the recommended level of care was 23 hour observation. The "Disposition ER" indicated "Psychiatric Hospitalization 23 hour observation" The "Physician Assessment and Certification - Patient Transfer Under EMTALA/COBRA" indicated on the line item titled "Receiving Hospital" that the patient was transferred to the outpatient psychiatric clinic on 4/20/15 at 7:18 p.m. with a diagnosis of "Danger to self/SI" (suicidal ideation). The indicated reason for transfer was "psych facility."

On 10/6/15 at 10:33 a.m., during an interview, the Integrated Urgent Services Manager (IUSM) stated he was an on-call mental health provider. He is a Licensed Clinical Social Worker. He was the mental health provider who performed the psychological assessment for Patient 3. When asked if a patient on a 5150 hold was considered psychologically stable he stated "No, that is why we put them on a 5150." He stated he recommended a 23 hour observation period for Patient 3 because it was possible the patient's behavior was caused by methamphetamine use. The effects of the drug could clear up in 23 hours and the patient may no longer need psychiatric care. A review of Patient 3's clinical record indicated a Drug Screen, urine (a test to determine the presence of specific drugs such as methamphetamine) was ordered at 12:21 a.m. on 4/20/15. A nurse's note at 1:37 a.m. on 4/20/15 indicated "Pt [patient] no [not] cooperative, unable to collect urien [urine] specimen, Dr. [physician name] informed." A review of Patient 3's clinical record indicated there were no lab results for a drug screen. When asked if it were possible the hospital could monitor the patient for these 23 hours the IUSM stated no because they (patient) could leave. When asked about the presence of a security guard outside the patient's room he stated "Well, they are there, don't know if they'll stop someone." A tour of the ED was conducted on 10/5/15. During the tour at 10:43 a.m., a security guard was observed standing outside a patient's ED room. The DED stated if a patient is on a 5150 hold or a 1799 hold (California Welfare and Institutions Code 1799.111 allows physicians to hold a patient for up to 24 hours, if they may be a danger to themselves or others, without liability) a security guard stands by until the patient is transferred or the hold is lifted.

Patient 4's clinical record indicated he was brought by ambulance to the ED at 9:13 p.m. on 3/7/15 and triaged as an acuity level of "2 Emergent." A medical screening exam was conducted on 3/7/15 at 9:32 p.m. and Patient 4 was medically cleared. A psychological assessment was conducted on 3/8/15 at 12:12 a.m. The recommendation for the level of care needed was "5150 hold for DTS/DTO." The "Disposition ER" indicated "Psychiatric Hospitalization 5150 hospitalization at designated psychiatric facility." The "Physician Assessment and Certification - Patient Transfer Under EMTALA/COBRA" indicated on the line item titled "Receiving Hospital" that the patient was transferred to the outpatient psychiatric clinic on 3/8/15 at 9:00 a.m. with a diagnosis of 5150 DTS/DTO. The reason for transfer listed was "Psychiatric."

Patient 5's clinical record indicated he was brought by ambulance to the ED at 1:52 p.m. on 7/6/15 and was triaged with an acuity level of "2 Emergent." A medical screening exam was conducted at 1:57 p.m. (note time 2:13 p.m.) and the patient was medically cleared. A psychological exam was conducted on 7/6/15 at 6:13 p.m. The recommended level of care needed indicated 5150 for DTS and the "Disposition ER" indicated Psychiatric hospitalization 5150 hospitalization at designated psych facility. " The "Physician Assessment and Certification - Patient Transfer Under EMTALA/COBRA" indicated on the line item titled "Receiving Hospital" that the patient was transferred to the outpatient psychiatric clinic on 7/7/15 at 11:30 p.m. with a diagnosis of Suicidal/Depression. The reason for the transfer listed was "specialized care."

On 10/7/15 at 11:05 a.m., during an interview with the Chief of the Emergency Department (CED) and the Director of the Emergency Department (DED), in response to the question: has a medical patient (versus a psychiatric patient) ever been transferred to an outpatient clinic, the DED stated "No, this is never done for medical patients because under EMTALA we have to transfer them to a hospital. We can't transfer them to a lower level of care."

On 10/8/15 at 1120 a.m., during an interview, the Chief of Psychiatry (CP) stated she participated in the process of approving the CS outpatient clinic for use by the hospital. She stated she conducted a site visit of the CS outpatient psychiatric clinic. She did not recall whether EMTALA regulations were discussed. She stated it was clinical judgement as to whether to send a patient to the CS outpatient psychiatric clinic. She stated she considered the outpatient clinic to be a higher level of care than what could be provided in the hospital's ED. She stated the patient would get a higher level of care, be treated and released on some occasions or would get transferred to another facility on other occasions. When asked what she meant by "another facility" she stated "Such as a psychiatric hospital." When asked whether there was always the potential for a patient on a 5150 72 hour hold to be transferred from the 23 hour CS psychiatric clinic to an inpatient psychiatric hospital, she stated they "hope 23 hours is all that is needed but it is a 23 hour facility." She then stated she would leave it to [the outpatient clinic name] to respond to."

The contract between the hospital and the outpatient psychiatric clinic titled "Healthcare Services Agreement Between [Hospital organization name] and [outpatient psychiatric clinic name] for Psychiatric Observation Services," with a final signature date of 6/11/13, indicated in Exhibit 1.6, page 1 "...Services to be Provided. ...Psychiatric Inpatient Services. Contractor shall provide psychiatric Inpatient Services, which shall Include: There are no Inpatient Services."

The California Department of Health Care Services (DHCS) lists the outpatient psychiatric clinic used by the hospital as a "County LPS [Lanterman Petris Short Act aka Welfare and Institutions Code sec. 5000 et seq] Designated Outpatient Clinic and Crisis Stabilization Unit. DHCS also lists four County LPS designated 24 hour facilities. The CS outpatient psychiatric clinic used by the hospital is not on the 24 hour list.