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Based on review of policies, procedures, documents, and staff interviews, the psychiatric hospital refused to accept an appropriate transfer of patients (# 1, 2, 3, 4, and 5) who had a psychiatric emergency when requested by an emergency department (ED) at critical access hospitals (CAHs) A, B, E, G and H. The psychiatric hospital had 24 psychiatric beds for adults and 12 psychiatric beds for children. The Psychiatric hospital had an average of 45 scheduled adult admissions per month, and had an available adult psychiatric bed at the time each CAH's ED requested an appropriate transfer for patients # 1, 2, 3, 4, and 5.

The Mental Health Institute (MHI) in Cherokee, Iowa is a psychiatric hospital with specialized capabilities in psychiatry. MHI is a participating hospital, receiving payment for services from Medicare and Medicaid.

Failure of the psychiatric hospital to accept appropriate patient transfers within its capacity and capability potentially resulted in the delay of the specialized care and stabilizing treatment for patients with psychiatric emergencies.

Findings include:

1. Review of policies/procedures revealed the hospital lacked a policy or procedure that addressed EMTALA requirements and the hospital's responsibility as a recipient hospital with specialized psychiatric capabilities to accept patients with a psychiatric emergency from a hospital or critical access hospital (CAH) ED.

During an interview on 7/8/14 at 8:10 AM, Staff D, Interim Superintendent, acknowledged the hospital lacked a policy/procedure that addressed EMTALA requirements and the psychiatric hospital's responsibility as a recipient hospital with specialized psychiatric capabilities to accept patients with a psychiatric emergency from another hospital.

2. Review of hospital policy titled "Admission Policy - Acute Care", revision date of September 2012, revealed in part ". . . Patients will be admitted to the hospital based on their need for acute care, not based on their ability to pay."

3. During an interview on 7/8/14 at 11:35 AM, Staff A, Director of Health Information Management (HIM), acknowledged the hospital is a psychiatric hospital. Staff A reported that when a physician from another hospital or CAH calls with an admission referral, the admissions department staff take the information, complete an admission referral form, has the referring hospital or CAH obtain laboratory tests and send the reports to MHI. The hospital receives referrals from 41 counties and every county has a central point coordinator (CPC) that manages mental health dollars for the county. Staff A reported the process includes a review of the patient's source of payment and if the patient has a payment source of Title 19 (Medicaid), the requesting physician is directed to call the applicable county CPC to get approval for the patient's admission to the hospital.

During an interview on 7/9/14 at 9:35 AM, Staff B, Admissions, verified that if another facility calls with an admission referral and the adult patient has Title 19 [Medicaid], the other facility is told to call the CPC in the county where the patient resides for approval. The facility making the referral is responsible for calling the CPC to get approval for the patient admission due to payment source.

4. Review of documentation from Iowa Department of Human Services revealed Central Point Coordination is an administrative function and is a component of the managed system required by the state. The CPC duties include centralized intake for persons wishing to access county funded mental health services and authorizing funding of services within the guidelines established by the county management plan.

Refer to A-2411 for additional details for Patients #1, 2, 3, 4, and 5.

Based on review of policies, procedures, medical records, referral documents, and interview with staff, the psychiatric hospital refused to accept appropriate transfers of patients # 1, 2, 3,4, and 5 who had emergency psychiatric conditions, when requested by the emergency departments (EDs) of critical access hospitals (CAHs) A, B, E, G and H. The psychiatric hospital staff reported accepting an average of 45 scheduled adult admissions per month. The psychiatric hospital had 24 psychiatric beds for adults and 12 psychiatric beds for children. At the time of the requests to transfer Patients #1, 2, 3, 4, and 5, there were available adult psychiatric beds at MHI. MHI had the capacity and capabilities to accept each of the 5 patients at the time of the request to transfer.

The Mental Health Institute (MHI) in Cherokee, Iowa is a psychiatric hospital with specialized capabilities in psychiatry. MHI is a participating hospital and receives payment for services from Medicare and Medicaid.

Failure to accept appropriate transfers within the capacity and capabilities of the psychiatric hospital potentially resulted in the delay of appropriate care and stabilizing treatment of patients with psychiatric emergencies.

Findings include:

1. Review of MHI on-call schedule for 6/3/14 revealed that Practitioner B, Physician Assistant (PA), was the on-call provider for psychiatry when CAH A requested to transfer Patient #1 to MHI.

2. Review of hospital policy titled "Admission Policy - Acute Care", revision date of September 2012, revealed in part ". . . It is the policy of the Mental Health Institute, Cherokee, Iowa to admit adults, adolescents, and children who are in need of evaluation and treatment at the acute level of psychiatric care. . . Patients will be admitted to the hospital based on their need for acute care, not based on their ability to pay. . . ."

3. Review of criteria for admission provided by Physician A, psychiatrist and MHI's Medical Director, revealed, in part, "A. Justification for Admission: The patient must meet at least two of the criteria for the non-physician reviewer to approve the admission. If the patient does not meet two criteria, the case must be referred to a physician reviewer for a medical necessity determination. A court order alone is not a medical indication for admission to MHI. 1. Suicidal indications (within last 48 hours) necessitating 24 hour professional observation supported by medical record documentation. 2. Assaultive intent and/or behavior with significant threat to the safety of self or others (within last 48 hours). . . 3. Documented failure of current outpatient treatment. . . 4. Monitoring of psychotropic medication with documented onset of severe side effects in the presence of complicating medical and/or psychiatric conditions necessitating observation and assessment by a professional nurse. . . 5. Need for 24 hour professional observation, evaluation, and/or diagnosis of a patient exhibiting behaviors consistent with psychiatric disorder which may include significant mental status changes. . . ."

4. During an interview on 7/9/14 at 8:35 AM, Staff C, Administrator of Nurses, stated the MHI has enough nursing staff to care for patients if all the available beds were full at all times but may increase the number of staff depending on patient needs or scheduling.

During an interview on 7/9/14 at 9:35 AM, Staff B reported she worked in the Admissions Office and stated that if another facility calls with an admission referral and the adult patient has Title 19 [Medicaid], the other facility is told to call the CPC in the county where the patient resides. The facility making the referral is responsible for calling the CPC to get approval for the patient admission to MHI due to the payment source of Title 10 (Medicaid).

During an interview on 7/9/14 at 10:45 AM, Physician A, Psychiatrist and MHI Medical Director, acknowledged the MHI at Cherokee furnishes care for children, adolescents, and adults needing psychiatric care as long as they meet the admission criteria. Physician A stated admissions are handled through the admissions office and he is not usually involved unless the patient had additional medical needs. The admissions staff may have questions about services we can not provide treatment for here such as IVs. The admissions department accepts the patients on my behalf and I see the patient when they come to the hospital.

During an interview on 7/9/14 at 10:55 AM, Practitioner B, Physician Assistant (PA), reported being on call on Tuesdays including 6/3/14, the day CAH A requested MHI to accept a transfer for Patient #1. Practitioner B stated adult psychiatric patient admissions are planned and scheduled through the admissions department but she puts orders in for patients scheduled to arrive prior to leaving for the day.

During an interview on 7/8/14 at 11:35 AM, Staff A, Director of Health Information Management (HIM), acknowledged the hospital is a psychiatric hospital. Staff A stated that when a physician from another hospital calls with an admission referral, the admissions department staff takes the information, fills out an admission referral form, has the referring hospital obtain laboratory tests and send the reports to MHI. The hospital receives referrals from 41 counties and every county has a central point coordinator (CPC) that manages mental health dollars for the county. Staff A stated the hospital looks at the patient's source of payment and if the patient has a payment source of Title 19 [Medicaid] the physician is directed to call the county CPC in the county where the patient resides to get approval for the patient's admission to the hospital. The CPC then gives approval for the admission of the patient to MHI.


5. Review of Cherokee Mental Health Admission Referral forms and medical record documentation received from the transferring CAHs for Patients #1, 2, 3, 4, and 5 revealed the following information. Review of the Daily Ward Reports for the MHI Adult Psychiatric Units revealed beds were available for each the following patients with an emergency psychiatric condition.


a. On 6/3/14 at 12:32, Patient #1 was brought to the ED at CAH A by police. The patient had a history of previous suicide attempts. The patient told another worker at his place of employment that he was depressed and had a plan to cut his arm with a knife. The patient's medical record at CAH A revealed the patient had a history of attention deficit hyperactivity disorder (ADHD), anxiety, depression, post traumatic stress disorder (PTSD), and suicidal ideation. The patient was described as cooperative but he was still having thoughts of hurting himself and had a specific plan. CAH A did not have the capability or capacity to provide stabilizing treatment for Patient #1's psychiatric emergency.

The CAH's medical record showed CAH A contacted MHI but MHI refused to accept the transfer because he had Medicaid. Patient #1 met MHI criteria for inpatient admission due to suicidal ideations within the last 48 hours necessitating 24 hour professional observation and assaultive intent with significant threat to the safety of himself and others as documented in the CAH's medical record.

Documentation on MHI's Admission Referral Form for Patient #1 revealed the following information. On 6/3/14 at 2:30 PM, MHI received a call from CAH A's Emergency Department Physician C to request admission for Patient #1 who had suicidal ideations with plans to cut himself. The payment source for Patient #1 was identified as Title 19 [Medicaid] on the form. Written under the comment section on the form was "needs CPC OK". This indicated that MHI told CAH A that the CAH A staff would need to call the county CPC to obtain approval for the admission of Patient #1 to the MHI based on the patient's payment source.

Review of the MHI Daily Ward Report for the Adult Psychiatric Units for 6/3/14 revealed there were 6 available adult psychiatric beds. During an interview on 7/9/14 at 7:40 AM, Staff A confirmed the availability of an adult patient bed on 6/3/14 based on the census sheet.

CAH A transferred Patient #1 to Acute Care Hospital C in another state at 6:35 PM.

b. Patient #2 presented to the Emergency Department of CAH B on 5/22/14 at 7:39 AM and was found to have an emergency psychiatric condition requiring inpatient psychiatric care and further stabilization during a medical screening exam. Patient #2 had suicidal ideations and had thoughts of cutting his wrist with a knife. The patient reported he had taken 10 Ativan pills the prior week when he was upset and he attempted to hang himself two weeks earlier but "the rope broke".

CAH B did not have the capability or capacity to provide stabilzing treatment for Patient #2's psychiatric emergency condition. The medical screening exam in the ED revealed the patient had suicidal ideations and reported two recent suicide attempts. The CAH staff began to call hospitals searching for a psychiatric bed beginning at 8:29 AM on 5/22/14.

Documentation in Patient #2's ED record shows the CAH staff contacted MHI in Cherokee at 10:32 AM on 5/22/14 with a request to accept the transfer of Patient #2. MHI requested that the CAH B "contact the county's CPC" to obtain approval for the admission.

Documentation of the MHI's admission referral form for Patient #2 included the following information. On 5/22/14 at 10:32 AM, MHI received a call from CAH B's Emergency Department (ED) requesting to transfer Patient #2. The patient had presented at the CAH's ED with suicidal ideations and a plan to use a knife to cut his wrists. There were two recent failed suicide attempts. The payment source on Patient #2's Admission Referral form was Medicaid. Written under the comment section on the form was "Call County X CPC". This indicated that MHI told CAH B that they would need to call the county CPC to obtain approval for the admission of Patient #2 to the MHI based on the patient's payment source.

When requested by CAH B, MHI refused to accept Patient #2 because the patient had Medicaid according to the documentation on MHI's Admission Referral form. MHI had the capacity and capability to accept the transfer of Patient #2 from the CAH B on 5/22/14 but refused the transfer. Patient #2 met the MHI criteria for admission due to suicidal ideations within the last 48 hours necessitating 24 hour professional observation and assaultive intent with significant threat to the safety of himself and others as documented in the patient's medical record for CAH B. MHI had 9 available adult beds on the adult psychiatric unit according to the 5/22/14 daily ward report.

Patient #2's medical record at CAH B revealed an acute care hospital accepted the transfer at 12:40 PM on 5/22/14 and the patient was transferred to the Acute Care Hospital D at 1:25 PM.

c. Patient #3 came to the ED at CAH E on 6/3/2014 at 2:24 PM by ambulance for evaluation of suicidal ideation. The police responded to a call concerning a suicide attempt. The patient reported ingesting a bottle of Tramadol (narcotic-like pain reliever) and locked himself in his room around 10:00 AM that morning and the police had to kick the door in to gain access to the patient. Upon arrival in the ED the patient denied taking the Tramadol but continued to admit that he wished to kill himself and had several ways to do so.

Patient #3 was found to have an emergency psychiatric condition requiring stabilizing treatment and psychiatric inpatient care following a medical screening exam at CAH E's ED. CAH E lacked the capability and the capacity to provide patient # 3 with treatment to stabilize his psychiatric emergency or provide inpatient psychiatric care.

On 6/3/14 at 4:00 PM, MHI received a call from Practitioner D, a physician assistant (PA) at CAH E. The caller requested admission for Patient #3 who had suicidal ideations and stated he wanted to kill himself.

Documentation of the MHI's Admission Referral form revealed the following. The payment source for Patient #3 was identified as Title 19 (Medicaid). Written under the comment section on the form was "CPC needs OK". This indicated that MHI told the PA at CAH E that he would need to call the county CPC to obtain approval for the admission of Patient #3 to the MHI based on the patient's payment source. A small note was paper-clipped to the Admission Referral form with the comment "CPC did NOT approve admission." Patient #3 met MHI criteria for admission due to suicidal ideations within the last 48 hours necessitating 24 hour professional observation and assaultive intent with significant threat to the safety of self as documented in the CAH's medical record.

Review of the MHI Daily Ward Report for the Adult Psychiatric units for 6/3/14 revealed there were 6 available beds for adult patients. MHI had the capacity and capability to accept the transfer of Patient #3 from the CAH E on 6/3/14 but refused the transfer.

CAH E transferred Patient #3 to Acute Care Hospital F at 6:15 PM.


d. Patient #4 presented to CAH G's Emergency Department on 4/21/14 at 6:35 AM and was found to have an emergency psychiatric condition requiring stabilizing treatment during a medical screening exam at CAH G's Emergency Department. Patient #4 required inpatient psychiatric care because of her visual and auditory hallucinations, paranoid delusions and bizarre behavior. The transferring CAH lacked the capability and the capacity to provide specialized psychiatric care for Patient #4.

When transfer of the patient was requested by CAH G, MHI refused to accept Patient #4 because the patient had Medicaid according to documentation found on the MHI Admission Referral form.

According to documentation found in the patient's medical record of the CAH making the referral, the MHI had the capacity to accept the transfer of Patient #4 from CAH G on 4/21/14, but did not accept the transfer. MHI offered inpatient psychiatric services and had 6 available beds at the time CAH G contacted MHI requesting to transfer the patient.

Documentation on MHI's Admission Form for Patient #4 revealed the following information. On 4/21/14 at 9:25 AM, MHI received a call from CAH G's Emergency Department to request admission for Patient #4 who was exhibiting bizarre behavior with visual and auditory hallucinations that required mental health evaluation and inpatient psychiatric care. The payment source for Patient #4 was Title 19. The comment section on the form indicated the "CPC needs to OK". This indicated that MHI told CAH G that the CAH would need to call the county CPC to obtain approval for the admission of Patient #4 to the MHI based on the patient's payment source.

Patient #4 met the MHI criteria for admission due to assaultive intent and/or behavior with significant threat to self within the last 48 hours and need for 24 hour professional observation, evaluation and/or diagnosis of a patient exhibiting behaviors consistent with acute psychiatric disorder as documented in the patient's medical record. MHI delayed the patient's psychiatric care and stabilizing treatment by their refusal to accept Patient #4.

CAH G admitted Patient #4 to their CAH at 4:30 PM because the CAH could not locate an appropriate receiving hospital to accept the patient.

e. Patient #5 presented to Emergency Department at CAH H on 5/29/14 at 7:54 AM by ambulance. The patient had a history of anxiety and depression according to the physician's ED note. The patient reported he had a severe headache with nausea that started yesterday. The patient rated the pain as a 10 on a 0 to 10 scale with 10 being the most severe pain. He described the pain as being on the left side of his head from the temple down to the back of his neck. The patient reported he had been in a car accident on 5/27/14 and had the headache since the car accident. He reported he had been going only about 5 miles per hour at the time. The patient reported he had been treated in an acute care hospital's ED on the prior day. An IV was started for IV fluids and the patient was given Toradol (pain relieving medication). Then the patient left Against Medical Advice (AMA).

Patient #5 returned to CAH H's ED at 1:40 PM and his wife came with him. The patient's wife stated that she did not feel safe with him at home. She reported that he wanted to be free of the pain that he is in and can't be trusted with medications. Patient #5 told his wife that he wished he could die the previous evening. The patient's urine drug screen was positive for propoxyphene, tricyclic antidepressants, oxycodone, opiates, and benzodiazapines. The patient's wife reported the patient had numerous pills at home and tends to take what ever he has regardless of what the doctors prescribe.

During Patient #5's second presentation, the physician documented the patient had suicidal ideation and a history of narcotic dependence and was a danger to himself. A court committal was obtained for the patient because the patient was found to have an emergency psychiatriccondition requiring inpatient psychiatric care during a medical screening exam at CAH H's Emergency Department. The transferring CAH lacked the capability and the capacity to provide stabilizing psychiatric treatment for Patient #5's emergency.

MHI received a call from CAH H Emergency Department to request to transfer Patient #5 for inpatient psychiatric care on 5/29/14 at 3:23 PM. Patient #5 had suicidal ideations and presented a danger to himself. When requested by CAH H, MHI did not accept the request to transfer of Patient #5 to MHI for inpatient care.

MHI had the capacity and capability to accept the transfer of Patient #5 from the CAH H on 5/29/14 but did not accept the transfer. Review of the MHI Daily Ward Report census sheet for 5/29/14 revealed there were 8 available adult psychiatric beds at MHI. Patient #5 met MHI criteria for admission due to suicidal ideations within the last 48 hours necessitating 24 hour professional observation and assaultive intent with significant threat to the safety of self as documented in the medical record.

CAH H transferred Patient #5 to Acute Care Hospital I after the court committal papers were signed by a judge at 5:54 PM.

f. The MHI staff were able to provide documentation that confirmed MHI received calls for emergency transfer of Patients #1, 2, 3, 4, and 5 with emergency psychiatric conditions. At the time of the calls, the psychiatric hospital had available adult psychiatric beds as stated in the above cases and the MHI did not accept any of the transfer requests. All 5 patients met the MHI criteria for inpatient admission due to their suicidal ideations and threat of harm to self or others.

6. Review of documentation from Iowa Department of Human Services revealed Central Point Coordination is an administrative function and is a component of the managed system required by the state. The CPC duties include centralized intake for persons wishing to access county funded mental health services and authorizing funding of services within the guidelines established by the county management plan.

Refer to A 2400 for additional information.