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Based on interview and record review the facility failed to follow their policy, and medical staff guidelines regarding acceptance of a psychiatric (psych) transfer (Patient #17). The facility census was 136. The psychiatric unit census was 10.

Findings Included:

1. Record review of an insert into the facility's Medical Staff Guidelines, under the miscellaneous tab, titled, "The Interplay Between Missouri's Trauma Center Law and Federal EMTALA (Emergency Treatment and Labor ACT)," undated, showed the following:

-Southeast Missouri Hospital is a "rural referral center" for purposes of the Medicare program. Under EMTALA a rural referral center CAN NOT refuse to accept an incoming transfer unless it does not have the capability to treat the patient.
-The decision when and where to transfer a patient already in another hospital's emergency department (ED) is for that ED physician who is currently with the patient to make in accordance with EMTALA. These decisions cannot be second guessed or overruled by the receiving hospital.
-The only acceptable reasons for refusing to accept an incoming patient are:
No physician of the needed specialty is on-call;
The specialist on-call is presently too busy with other patients to assess the incoming patient;
The diagnostic capabilities needed for the incoming patient are not available;
The hospital's ED is overwhelmed.

Record review of the facility's policy titled, "Emergency Medical Screening Treatment and Labor Act," dated 07/08, showed the following:

-Unless expressly assumed by the accepting physician, all responsibility for a medically appropriate transfer of the patient shall be that of the transferring physician.
-Patient transfers with emergency medical conditions may be declined on the following grounds:
Lack of available capacity;
The patient is not in need of the specialty care facilities of this hospital;
The patient does not have an emergency medical condition;
The risks of the transfer outweigh the benefit to the patient.

Review of Southeast Missouri Hospital's Psychiatric Patient Referral Form, dated 05/06/11 showed Staff B, the psychiatric intake nurse received a call at 11:10 AM from Hospital #1 requesting to transfer Patient #17. Staff B documented the reason for referral as, "Something not right, wants to kill self," "Has had suicidal ideations for the past several weeks but worse today." Staff B notified Physician A at 1:40 PM and documented that patient #17 was not accepted for transfer, and that Physician A would call the Social Worker at Hospital #1.

Review of Hospital #1's medical record showed the Social Worker, Staff E, documented contact with Southeast Missouri Hospital's psychiatric intake nurse, Staff B, and was told they had a bed and to FAX information about patient #17. Further documentation showed that Physician A called hospital #1 and told Staff E patient #17 had a history of malingering and felt the patient needed to go to another hospital. Staff E contacted a second hospital where patient #17 was accepted for transfer.

During an interview on 05/24/11 at 11:04 AM, Physician A, stated Patient #17 had been admitted several times previously and that the patient had a tendency to be noncompliant with appointments and medication refills. Physician A stated he knew this patient quite well and felt this patient had established a pattern of requesting admission when convenient.

During interviews on 05/19/11 at 1:20 PM, Staff D, Director of Patient Care, stated that the psychiatric unit is a co-ed unit with a capacity of 14-beds, and admits patients ages 18 and older. On 05/06/11, the psychiatric unit had a bed to accommodate patient #17 (the census was six at the time of the transfer request) and that the psychiatric unit had the capability to treat patients with depression and suicidal ideation. Staff D confirmed that Physician A was on duty at the time the Social Worker from Hospital #1 called to arrange this transfer.

Physician A failed to follow hospital policy and did not accept hospital #1's request to transfer patient #17 even though the psychiatric unit had the capacity and capability to treat patient #17.

Based on interview and record review the facility failed to accept a psychiatric patient (Patient #17) with an emergency medical condition, that they had the capacity and capability to treat. The facility census was 136. The psychiatric unit census was 10.

Findings Included:

1. Record review of the facility's policy titled, "Emergency Medical Screening Treatment and Labor Act," dated 07/08, showed the following:

-Unless expressly assumed by the accepting physician, all responsibility for a medically appropriate transfer of the patient shall be that of the transferring physician.
-Patient transfers with emergency medical conditions may be declined on the following grounds:
Lack of available capacity;
The patient is not in need of the specialty care facilities of this hospital;
The patient does not have an emergency medical condition;
The risks of the transfer outweigh the benefit to the patient.

Review of Patient #17's ED record from the transferring hospital (hospital #1) showed the following:

-Patient presented to hospital #1's ED on 05/06/11 complaining of depression and suicidal thoughts.
-The ED physician assessment showed the patient was anxious, depressed, and had suicidal thoughts.
The ED physician recommended transfer;
-The ED nursing assessment showed the patient had suicidal thoughts.
- ED nurses' notes showed the patient stated, "I wish I could die," "I am just worthless," and everyone
would be better off without me."
-A Mental Health Assessment, completed in the ED by Staff E, Social Worker, showed the patient had thoughts of killing her/himself. The patient was shaking, crying and vomiting. The patient had a flat affect, poor insight and judgement. Staff E recommended the patient be transferred to inpatient psych treatment. Staff E called Southeast Missouri Hospital (patient's preference) and was told they had a bed and to send patient information to them. Later, the psychiatrist from Southeast Missouri Hospital called and said the patient had a history of malingering and felt the patient needed to go to another hospital. Hospital #1 transferred Patient #17 to hospital #3.

During interviews on 05/19/11 at 1:20 PM, Staff C, interim Director of the psychiatric unit, stated a referral entity calls into the psych unit and is referred to the appropriate staff, as assigned that day, to document the intake. Staff D, Director of Patient Care, stated that this psychiatric unit was a co-ed unit with a capacity of 14-beds. The unit admits patients ages 18 and older. On the date of this specific referral, 05/06/11, there was a gender specific bed available (the census was six at the time of the referral), and the psych unit is capable of assessing and treating patients with depression and suicidal ideations. Staff D stated Physician A was on duty when this referral came in. Physician A determines acceptance/admission.

During an interview on 05/19/11 at 1:40 PM, Staff B, the psychiatric Registered Nurse (RN), receiving the intake for the referral of Patient #17, stated he/she remembered the call and the patient as he/she had been on their unit several times for suicidal attempts and ideations. Staff B stated the referral form was completed and the information was passed on to Physician A over the phone. Only the labs and referral was read to Physician A, not the nurses' notes or the assessment by the ED at hospital #1. Physician A told Staff B he wanted to research this patient's history on the computer and said this referral sounded like previous admissions and did not know if the patient needed admission. Physician A did not call Staff B back with a decision to admit by 1535 (3:35 PM) that day so Staff B assumed Physician A declined the admission. Staff B confirmed the psychiatric unit cared for patients with severe depression, suicide ideations and attempts, psychosis, and homicidal ideations if not currently violent.

Review of Patient #17 ' s previous admits showed the patient had been admitted to the psych unit on 10/07/10, 10/30/10, 12/01/10, 12/09/10, and 02/20/11.

During an interview on 05/24/11 at 11:04 AM, Physician A stated that the patient had been admitted several times to their facility, plus had called the unit while an outpatient. The patient had a tendency to be noncompliant with appointments, and medication refills. The patient had been admitted on 02/20/11 with a diagnosis of malingering related to homelessness, and another time for failing to follow through on medication refill, again malingering. Physician A said he knew this patient quite well and felt this patient had established a pattern of requesting admission when convenient to a particular situation, probation meeting, out of pills, etc. Physician A said he called the Social Worker, Staff E, at hospital #1 and described the patient's history of repeat admissions and malingering. Physician A said Staff E at hospital # 1 agreed the patient did not have an emergency condition, and did not need admission.

During an interview on 05/24/11 at 3:35 PM, Staff E, Social Worker (SW) at hospital # 1, said she spoke with Physician A on 05/06/11 (time unknown-but after a mental health assessment in the ED) and Physician A told her Patient #17 had been in his psychiatric unit many, many, many times and was noncompliant with follow-up appointments and medications. Physician A told Staff E based upon the numerous visits and history of malingering he did not feel his psych unit was able to do anything more and patient # 17 would be better off going elsewhere. Staff E called hospital #3 and they accepted patient # 17 for transfer. Staff E denied agreeing with Physician A when he determined the patient did not have an emergency medical condition, and did not need hospitalization because of her history of non-compliance.

During interviews on 05/24/11 at 11:39 AM, Licensed Practical Nurse on duty, Staff H, said he/she remembered the patient coming into the ED with suicidal ideations and had discarded all her pills. The SW assessed the patient in the ED. Staff I, Director of the ED at hospital #1 said the SW called Southeast Missouri Hospital and he/she was told they could not take the patient as he/she had been there a lot for the same thing and there was nothing they could do for her. The patient needed to go to another facility. The patient went to hospital #3 by ambulance.

Review of 20 additional ED and/or psychiatric referrals revealed two additional records that exhibited similar diagnoses and also recidivism/re-admission several times for psych complaints. Patients #2, and #4, were both admitted after presenting to Southeast Missouri Hospital's ED.

Southeast Missouri Hospital staff failed to accept the incoming transfer of Patient #17, even though the ED physician and SW at Hospital # 1 deemed the patient had an emergency medical condition warranting a psychiatric inpatient stay, and even though they had the capacity and capability to treat Patient #17.