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Based on review of hospital policies, medical records (MR), transfer request log and bed census from Hospital A (Decatur Morgan West, an affiliate of Decatur Morgan Hospital), Hospital A Pre-Admission Screening documentation, Hospital B (Sending Hospital) Emergency Department (ED) MR, and staff interviews, it was determined Hospital A failed to accept a transfer and admit a patient for psychiatric treatment when they had the capacity and capability to treat the patient.

This affected Patient Identifier (PI ) # 26, who presented to Hospital B ED on 10/6/23 with psychiatric symptoms including homicidal ideation and aggressive behavior, with prior diagnoses including Autism Spectrum Disorder (A complex developmental condition involving persistent challenges with social communication) and, ADHD (attention deficit hyperactivity disorder). PI # 26 required admission to an inpatient pediatric psychiatric facility. Hospital A refused to accept the transfer on 10/9/23, at 9:58 AM, and PI # 26 was transferred for direct admission to Hospital C (receiving hospital) on 10/10/23.

Findings Include:

Refer to A 2411 for findings.

Based on review of hospital policies, medical records (MR), transfer request log and bed census from Hospital A (Decatur Morgan West, an affiliate of Decatur Morgan Hospital-Decatur Campus specializing in psychiatric care), Hospital A Pre-Admission Screening documentation, Hospital B (Sending Hospital) Emergency Department (ED) MR, and staff interviews, it was determined Hospital A refused to accept from Hospital B, a referring hospital within the boundaries of the United States, an appropriate transfer of an individual who required such specialized capabilities or facilities. Hospital A had the capability and capacity to treat the patient who had an emergency psychiatric condition.

This affected nine-year-old Patient Identifier (PI) # 26, who presented to Hospital B ED on 10/6/23 with psychiatric symptoms including homicidal ideation and aggressive behavior, with prior diagnoses including Autism Spectrum Disorder and ADHD (attention deficit hyperactivity disorder). PI # 26 required admission to an inpatient pediatric psychiatric facility and remained in Hospital B ED from 10/6/23 to 10/10/23 waiting for transfer.

Findings Include:

Facility Policy: Emergency Medical Treatment and Labor Act (EMTALA) - General Requirements and Definitions
Reference Number: None
Effective Date: 8/29/22

...II. Policy:

It is the policy of the Health Care Authority of the City of Huntsville for all HH (Huntsville Hospital) Health System acute-care or specialty hospitals to comply with...§ 1866 and §1867 of the Social Security Act, otherwise known as...EMTALA.

III. A. EMTALA General Requirements:

...7. The hospital will accept appropriate transfers of patients needing specialized services within the Hospital's capability and capacity to treat those individuals.

B. Definitions:

The following terms and definitions are used throughout the HH Health System policies and procedures to demonstrate consistency and compliance with all state and federal regulations related to EMTALA.

...2. Capabilities of a medical facility or hospital provider means the physical space, equipment, supplies and services (e.g. trauma care...psychiatry) at the hospital. The capabilities of the hospital's staff mean(s) the level of care that the hospital's personnel can provide within the training and scope of their professional licenses, including coverage available through the hospital's on-call roster.

3. Capacity means the ability of the hospital to accommodate the individual requesting examination or treatment of the transferred individual. Capacity encompasses such things as numbers and availability of qualified staff, beds, equipment and the hospital's past practices of accommodating patients in excess of its occupancy limits.

IV. Additional EMTALA Requirements:

...D. Appropriate Transfer Obligations:

...4. Recipient Hospital Responsibilities:

If a Receiving Hospital has the capacity and specialized capabilities to manage the care of an individual's EMC (emergency medical condition), and those capabilities are not available at the Transferring Hospital, the receiving hospital is obligated to accept the transfer from a referring hospital within the boundaries of the United States when requested.

Facility Policy: Capacity Plan/Admission Criteria
Guideline Number: C-1.00
Department: West Campus Nursing
Effective Date: November 2022

Purpose:

To outline admission criteria, exclusionary criteria, and admission processes at the Decatur Morgan Hospital-West Campus (DMH-West Campus).

Guideline:

...4. Exclusion Criteria:

a. Patients with a diagnosis of moderate retardation. (For the purpose of this policy this references patient with moderate to severe mental retardation or known IQ [Intelligence Quotient] of 69 or below).

1. Review of Hospital A (Decatur Morgan West) intake documentation revealed a request for transfer was received from Hospital B (transferring hospital) on 10/9/23 at 9:50 AM for a nine year old patient (PI # 26) with behavioral symptoms. Review also revealed a bed was available at Hospital A.

Further review revealed the status as, "not admitted," and reason documented for not admitting was an IQ < (less than) 70. Employee Identifier (EI) # 1, Registered Nurse (RN) at Hospital A documented, "FSIQ (Full Scale Intelligence Quotient) 55. Caller from Hospital B made aware.

Review of Hospital A's Transfer Log dated 10/9/23 at 9:58 AM revealed the request to transfer PI # 26 from Hospital B to Hospital A was not accepted due to IQ < 70.

Review of Hospital A's Children's Unit Bed Capacity from midnight 10/8/23 to midnight 10/9/23, revealed the 12 bed unit had four beds available. Hospital A had capability and capacity at the time of the transfer request from Hospital B. An interview conducted on 10/17/23 at 4:10 PM with EI # 3, Hospital A Nursing Director, confirmed there were no staffing issues and beds were available at that time.

In an interview conducted on 10/17/23 at 1:45 PM with EI # 2, Service Line Director at Hospital A, EI # 2 was asked for what reasons would a transfer request be denied at Hospital A, and EI # 2 stated if the patient was in their exclusion criteria, for example, an IQ 69 or below. EI # 2 confirmed IQ exclusion criteria was included in policy C-1.00, and the policy applied to pediatric patients.

EI # 2 further confirmed a diagnosis of autism did not exclude pediatric patients from admission, but an IQ of 69 or less would exclude a patient from admission because those patients didn't do well due to the facility's communal milieu. The children are placed in one large classroom where cognitive behavioral therapy is utilized as part of their treatment. Those with an IQ of 69 or less would not be able to function in that type of classroom environment.

Continuing with the interview, EI # 2 stated the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders stated an IQ of 69 or less equaled intellectually disabled. EI #2 confirmed that labs, medical clearance, Intake and Psycho-Social Assessment and documented IQ, if known, were obtained from the referring facility. EI # 2 confirmed Hospital A did have a 12 bed children's psychiatric unit for ages 4-12.

An interview conducted 10/18/23 at 8:58 AM with EI # 1, the RN who performed Hospital A's Pre-Admission Screening for PI # 26, confirmed referral information received included a physician narrative. EI # 1 confirmed the physician (psychiatrist) is not contacted if the patient meets exclusionary criteria. EI # 1 confirmed he/she checked bed capacity at Hospital A prior to talking with referring facilities.

Continuing the interview, EI # 1 was asked if he/she recalled a transfer request from Hospital B for PI # 26? EI # 1 stated yes, that there was something in the physician narrative regarding certain behaviors that indicated PI # 26's IQ was below 70. EI # 1 stated for PI # 26, he/she called the case manager at Hospital B and asked for his/her IQ. The case manager sent over psychiatric testing indicating PI # 26 had an IQ of 55. The patient met exclusion criteria, and all referral information was shredded at that time.

The surveyor attempted to contact PI # 26's mother via phone on 10/18/23 at 4:25 PM to inquire about PI # 26's IQ, but did not receive a response. The surveyor was unable to determine the source of the reported IQ of 55 for PI # 26.

Review of the ED (Emergency Department) MR from Hospital B, transferring hospital, revealed PI # 26 presented to Hospital B on 10/6/23 at 4:27 PM with his/her mother via private vehicle with a chief complaint of psychiatric evaluation. PI # 26's mother reported PI # 26 had tried to stab her multiple times with both scissors and a knife, that PI # 26 had stated multiple times he/she wanted to kill her, and that he/she had attempted to hurt his/her siblings and grandmother. The behavior had continued for three days and progressively worsened.

The ED MR revealed PI # 26 had a past medical history of ADHD, Autism, Autism Spectrum Disorder, Nocturnal Enuresis and Seizures.

Review of the ED Provider's Physical Exam note dated 10/7/23 at 4:36 AM revealed his/her clinical impression included homicidal ideation, behavior problem in pediatric patient, and oppositional defiant disorder, with comments PI # 26 had been evaluated and was stable for transfer and admission to a pediatric psychiatric facility.

Review of the ED Care Time Line and Quick Update Notes in the MR dated 10/6/23 to 10/10/23 revealed a total of eight pediatric psychiatric facilities were contacted requesting transfer for PI # 26, including a note dated 10/9/23 at 9:30 AM by Hospital B EI # 4, RN, who documented Hospital A had a potential opening and needed a Covid swab.

Further review of the ED MR from Hospital B revealed there was no documentation of PI # 26's IQ, or that an IQ test had been performed.

On 10/10/23 at 8:44 PM PI # 26 was transferred to Hospital C (receiving hospital).

The October 2023 Psychiatrist on -call schedule for Hospital A was reviewed. The on-call schedule verified that on October 9, 2023, a psychiatrist was on call when the request was made for transfer. The facility had the capability to admit and treat PI #26 on October 9, 2023.

The facility failed to ensure that their policy was followed, as evidenced by Hospital A had the capacity and specialized capabilities to admit and treat PI #26, who had an identified psychiatric emergency condition, the capabilities were not available at Hospital B. The hospital policy stated in part, "receiving hospital is obligated to accept the transfer from a referring hospital within the boundaries of the United States when requested."