HospitalInspections.org

Based on interviews, observations, and review of policies and procedures the hospital has not defined the requirements for its use of Qualified Medical Personnel (QMP) in bylaws, and/or medical staff rules and regulations, as required and as evidenced by:

Hospital campus A and campus B psychiatric emergency response team (PERT) members conduct psychosocial screening of behavioral health patients in the ED who may have emergency medical conditions (EMC) such as suicidal, and homicidal ideations. The hospital employs social workers of various educational levels LCPC (licensed clinical professional counselor, LSWC (licensed social worker clinician), and an unlicensed bachelor-prepared social worker to screen for EMC.

Neither the hospital rules, regulations or bylaws address qualifications of the personnel who conduct EMC screenings for behavioral health patients in the ED. Therefore, the hospital fails to meet the regulatory directive to determine the appropriate qualifications for those conducting EMC screenings.

Based on interviews, observations, and review of policies, procedures, medical records, and other pertinent documentation the hospital failed to accept transfers of patients #1, #2 and #3 of 12 patients reviewed with emergency medical conditions as required and as evidenced by:

The hospital consists of two campus's (campus A and B). Both campuses (A and B) have emergency departments. Campus B ( Dorchester General Hospital), however, also houses the 17-bed behavioral health unit (BHU) for both campuses. The hospital BHU is a locked unit. The BHU Director states the BHU has no acuity assessment system, though does assign levels of observation ranging from SP1 (hourly observation), SP2 (patients in constant eyesight), and SP3 (1:1 within arms reach).

A hospital policy entitled "Shore Behavioral Health Services Admission Procedures" has a stated purpose of defining "the procedures for twenty-four (24) hour medical screening of psychiatric admissions, emergencies, or referrals." This policy defines possible exclusion criteria for patient admission to the behavioral health unit as, (5.6 of the policy) individuals requiring police escort; (5.7) MR (Mental Retardation) whose level does not permit them to participate and benefit from group and other therapies on the unit; (5.10) individuals identified by prior admissions that have not and/or would not participate in or benefit from the program; and (5.12) chronic psychotic illness with a known history of need for prolonged inpatient stay.

The policy fails to disclose or provide that a patient with an Emergency Medical Condition (EMC) cannot be subject to these exclusionary criteria if the hospital has the capability and capacity to provide stabilizing treatment. Both patients #1, 2 and #3 had emergency medical conditions (EMC ' s) and were declined transfer under these guidelines without consideration of EMTALA requirements to accept these patients for transfer to provide stabilizing treatment.

Patient #1 is a 19-year-old male with a diagnosis of Impulse Control Disorder. A psychiatric emergency response team (PERT) tracking sheet for 7/11 at hospital campus (B), reveals calls from other hospitals requesting transfer to the BHU. A call from a remote hospital seeking transfer of patient #1 to the BHU was processed between 2:30 and 2:50 am. On 7/11/2010, the BHU had a census of 10 out of 17 beds, leaving a possible 7 beds for admissions. The " Disposition " column, of the tracking sheet states " Reject " with the deciding psychiatrist's name listed. No reason for the denial is indicated on the sheet.

Interview with the deciding psychiatrist of 7/11 reveals that patient #1 was denied on the basis of the psychiatrist's perceived unit acuity. He states that a male patient who was already on the behavioral health unit (BHU), might need seclusion and if accepted patient #1 might also need seclusion when the the unit has only one seclusion room.

Review of the documentation of that inpatient male revealed that he had been in seclusion on 7/7, 4 days prior to the request for placement of patient #1. A psychiatrist note of 7/11 regarding the inpatient male states in part, " Consensus agreement of much improvement over the past 2 days." When asked, this psychiatrist reported that he was new (6 weeks), and is not familiar with the details of EMTALA.

Based on interview with psychiatric medical staff, the hospital has not provided training in EMTALA requirements to the staff who make determinations of whether to accept or decline transfer of patients with EMCs from hospital EDs. In the case of patient #1, this resulted in a denial for transfers to hospital campus B - BHU.

The hospital had seven beds available, but did not admit patient #1 who had an emergency medical condition, based on the chance that both he and another patient might need the seclusion room simultaneously. The hospital had the capacity and capability to meet patient #1's treatment needs, but did not do so.

Patient #2 is a 56-year-old male with a history of mental retardation, psychosis, depression, and obsessive-compulsive disorder. He was brought to the hospital ' s (A) campus emergency department (ED) on 8/8/2010 at 4:23 pm, and was seen at 6:30 pm for evaluation of adverse behaviors at patient #2 ' s group placement. There he was reported to have not been eating meals, had locked himself in his room, become violent, and threatened to cut his arms and legs. The clinical impression was " Intermittent Explosive Disorder," and patient #2 was made involuntary. Prior to this presentation, patient #2 was well known the hospital. Census on the BHU of campus (B) on 8/8/2010 was 13.

Per the complainant, " We were told he (patient #2) could not be admitted because he was not Mild ID (Intellectual disability), but was diagnosed as Moderately ID." This statement correlates to (5.7) of the hospital Admission Criteria Adult Psychiatric Inpatient Policy, which does not distinguish between those who are voluntary patients, and those with emergency medical conditions.

Though the BHU on campus (B) had 4 beds available, patient #2 was restrained and remained in the ED for three days. After three days, patient #2 was transferred to a another behavioral health hospital for stabilizing treatment. The hospital failed to meet EMTALA regulations when the hospital had the capacity and capability to meet the treatment needs of patient #2 and did not do so.

Patient #3 is a 60-year-old male who presented to the emergency department of campus (B) on 5/26/2010, after becoming agitated and combative at his assisted living placement. Patient #3 stated he had " ...yelled a lot and took some swings " at staff who had angered him. Patient #3 verbalized suicidal ideation. The hospital certified patient #3 for involuntary admission and transferred him to a different hospital for psychiatric treatment when there were beds available in their unit.

No documented evidence was found that the hospital attempted to admit patient #3, to the BHU of campus (B), which had a census of 9, and a capacity of 17 beds. The hospital failed to meet EMTALA regulations when the hospital had the capacity and capability to provide stabilizing treatment to patient #3 and did not do so.