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Based on staff interviews and review of medical records, policies/procedures and Medical Staff Bylaws, the facility failed to comply with the Medicare provider agreement as defined in 489.20 and 489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

The facility failed to meet the following requirements under the EMTALA regulations:

Tag A2409 Appropriate Transfer
The facility failed to follow the Medical Staff Bylaws and have appropriately documented the transfer of a patient to a recipient hospital.

Tag A2411 Recipient Hospital Responsibilities
The facility failed to accept a patient from a transferring hospital.

Based on staff interview and review of medical records and the Medical Staff Bylaws, the facility failed to have appropriately documented the initiating of a transfer to a receiving facility in one (#9) of 20 medical records reviewed.

The findings were:

The Medical Staff Bylaws stated the following under Article XI: EMERGENCY MEDICAL TRANSPORT AND ACTIVE LABOR ACT in pertinent part:
"11.1 RESPONSIBILITY OF THE RECIPIENT HOSPITAL
As a recipient hospital, Colorado West Psychiatric Hospital has a responsibility to determine that a transfer has taken place in accordance with EMTALA requirements.
Requirements. The Transferring Hospital must perform the following functions to effect the transfer of an individual with an Emergency Medical Condition:
11.1.1 The treating physician or treatment QMP shall document his or her determination that the individual is stable for transfer in the medical record. If the treating QMP makes this decision, in consultation with a physician, the consulting physician shall counter-sign the determination in the medical record;...
11.1.3 The Transferring Hospital shall document its communication with the Recipient Hospital in the medical record, including the date and time of the communication and the name of the person accepting the transfer;...
11.2 OUR PRACTICE AS A TRANSFERRING HOSPITAL
In the off chance we become a transferring facility, we will do so using EMTALA criteria, per our CMS provider agreement..."
The medical record of sample patient #9 was reviewed on 8/31/11. The patient was transferred in from a local hospital on 8/8/11 with complaints of a suicide attempt. The patient became medically unstable and was transferred back to the local hospital. The following elements of the transfer form were not completed: Name of destination hospital, Accepting House Supervisor, RN report given to, Person obtaining hospital acceptance and Accepting physician. The "Consent/Refusal to Transfer" information for the patient was not completed nor signed by the patient. The "Reason for Transfer" was not completed. The date and time of "Pickup" were not completed.

An interview was conducted with the Administrator on 8/31/11 at approximately 10:00 a.m. The Administrator acknowledged that the transfer documents were not completed.

In summary, the facility did not follow their Medical Staff Bylaws in regards to the transfer of a patient to a recipient hospital thus also violating the EMTALA requirements.

Based on staff interview, review of medical records and the facility's policies/procedures, the facility failed to accept a patient from a transferring facility that had been accepted prior to arrival. Specifically, the patient arrived from the transferring facility and a staff member determined the patient could not be cared for and returned the patient to the transferring facility.

The findings were:

The facility's policy and procedure entitled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," stated the following in pertinent part: "To comply with the requirements of the federal Emergency Medical Treatment and Labor Act ("EMTALA")...and the regulations implementing EMTALA, found at 42 C.F.R. 489.24, when Colorado West Psychiatric Hospital accepts and receives individuals from another medical facility."

The transferring facility documented the following in the patient's medical record on 8/14/11: "This 59-year-old male was sent by the Sheriffs Department as a transfer from (transferring hospital name) to (accepting hospital name) in Grand Junction. They accepted transfer. The patient got down to the facility and he was turned away. The stated reasons from the accepting facility were that the patient could not be safely cared for at their facility because of his underlying multiple sclerosis."

The facility provided the following documentation on 8/30/11 regarding their investigation of the incident:

The following message via e-mail was documented by the receiving nurse to the Director of Nursing (DON) on 8/14/11 at 1600 (4:00 p.m.) and reads in pertinent part: "Client arrives via Sheriff's facility van, is unable to get out of the van without significant help, requiring (2)...nurses. Client also does not have a w/c (wheelchair) but a walker w/he (which he) can hardly manipulate. This client is assessed by nursing and declined admission...Client was placed back into the van with significant help. Left facility at 1615 (4:15 p.m.)."

The following message via e-mail was documented by the Medical Director to the DON and the receiving nurse on 8/15/11 at 8:00 a.m.: "Since I was here, it would have only taken a few minutes for one of us to come over, see the pt., drop the hold, and discharge him to home (instead of back to the hospital) with the sheriff providing him transport back to Glenwood."

The following message via e-mail was documented by the Administrator to the Medical Director, DON and the receiving nurse on 8/15/11 at 8:20 a.m.: "Yes, a doctor should have been consulted when the 'refusal' decision was made. I think we need to slow down in these situations and make a plan in the best interest of the patient as well as the hospital."

An interview was conducted with the Administrator on 8/30/11 at approximately 2:45 p.m. The Administrator stated they received an initial phone call from the transferring hospital regarding this patient and felt they could not adequately care for the patient and turned the hospital down. A second call was received from the transferring hospital and the story was somewhat different. We were informed that although the patient used a wheelchair, s/he was independent in ADLs (Activities of Daily Living) and transfer from the wheelchair. When the patient arrived, s/he had been shackled for the whole distance, had a walker but had difficulty standing on his/her own. Our facility has wheelchairs to use for these situations; however, the receiving nurse made the decision on her/his own and returned the patient to the transferring hospital. The Administrator further stated that "we knew we had an EMTALA violation and were prepared to report it to the proper authorities." We called the transferring hospital and they stated that they would report the violation and that we didn't have to.

In summary, the facility accepted a patient via telephone from the transferring hospital on 8/14/11. However, when the patient arrived the receiving staff made an independent decision and returned the patient back to the transferring hospital and violated the EMTALA requirement.