HospitalInspections.org

Based on review of Bylaws of the Medical Staff, Medical Staff Bylaws Appendix I, Rules and Regulations, policies and procedures, Utilization Management Program, medical records, AltaPointe Health Systems, EastPointe Hospital Consumer lists and interviews with facility staff, it was determined EastPointe Hospital failed to:

1) Ensure the on-call physician accepted Patient Identifier (PI) # 18 and # 15, which the facility had capacity and capability to treat. This affected 2 of 43 emergency department requests of patients appropriate for transfer to EastPointe Hospital, which had the capacity and capability to treat.

2) Accept medically stable consumers (patients) who required psychiatric inpatient treatment to stabilize their psychiatric conditions, which the facility had the capability and capacity to treat from referring hospitals' emergency departments. This affected 8 of 43, including Patient Identifier (PI) # 14, 16, 17, 19, 11, 1, 12 and 13 emergency department requests of patients appropriate for transfer to EastPointe Hospital, which had the capacity and capability to treat.

3). Accept appropriate transfers of patients from Emergency Departments (ED) of patients who were medically clear and stable for transport, but required continued psychiatric inpatient treatment based on a screening by the ED physician. This affected 10 of 43, including Patient Identifier (PI) # 1 on 1/14/16, 11 on 8/15/15, 12 on 2/21/16, 13 on 2/21/16, 14 on 2/20/16, 15 on 1/20/16, 16 on 1/30/16, 17 on 2/22/16, 18 on 2/11/16 and 19 on 1/14/16 emergency department requests of patients appropriate for transfer to EastPointe Hospital, which had the capacity and capability to treat.


Findings include:


Please refer to findings at A2404 - On Call Physician, A2406 - Medical Screening Examination and A2411 - Recipient Hospital Responsibilities for findings.

Based on review of Bylaws of the Medical Staff, Medical Staff Bylaws Appendix I, Rules and Regulations, policies and procedures, Utilization Management Program, medical records, AltaPointe Health Systems, EastPointe Hospital Consumer lists and interviews with facility staff, it was determined the on-call physician failed to accept Patient Identifier (PI) # 18 and # 15, which the facility had capacity and capability to treat. This affected 2 of 43 emergency department requests of patients appropriate for transfer to EastPointe Hospital (EP).

Findings include:

Review of the Bylaws of the Medical Staff revision date 10/14, revealed the following... Whereas, one of the primary goals of the Medical Staff is to provide consumer care commensurate with each consumer's individual need, the Medical Staff must work with the Chief Executive Officer and is subject to policies and disciplinary standards as necessary to fulfill the goals and objectives of AltaPointe Health Systems, Inc. in providing optimum quality of care to its consumers; and,

Therefore, licensed independent practitioners (LIP) practicing in this community mental health organization organize themselves into a Medical Staff in conformity with these Bylaws.

The Bylaws, when adopted by the Governing Body, create a mutually binding agreement between the Medical Staff and governing body, which may not be unilaterally amended...

Definitions:

The following definitions apply to the provisions of these Medical Staff Bylaws and its related manuals...

12. Licensed Independent Practitioner (LIP) shall mean an individual permitted by law and by the organization to provide care and services, without direction or supervision, within the scope of the individual's license and consistent with individually granted clinical privileges. At AltaPointe, such individuals include: MD (Medical Doctor), DO (Doctor of Osteopathy), Certified Nurse Practitioner, and a Physician Assistant.

13. Medical Staff or Staff shall mean that component of the company's organizational chart that stands for all practioners as defined below who are appointed to membership and are privileged to attend consumers or to provide diagnostic, therapeutic, services at the organization...

Section 2. Basic Qualifications for Membership.

Only a physician, nurse practitioner or physician assistant licensed to practice in the state of Alabama shall be eligible for membership in the Medical Staff who continuously meets the following requirements...

Article III. Categories and Privileges of the Medical Staff

... Section 2. Psychiatric Staff

a. Active

1. Qualifications: The active psychiatric staff shall consist of physicians who are eligible or board certified in psychiatry... certified nurse practitioners (CRNP) who are licensed by the Alabama Board of Nursing and Physician Assistant licensed by the Alabama Board of Medical Examiners...

Article IV. Active Categories and Privileges of the Affiliate Staff

Section 1. Active Affiliate Staff

a. Qualifications: Affiliate staff duties and privileges are subject to the bylaws, Rules and Regulations and policies, and policies of the Hospitals and Programs, and the applicable federal and state laws and regulations... Affiliate Staff designation may be extended to nurses with psychiatric training, counselors, psychologists, social workers, psychometrists, and other individuals specified herein who are professionally qualified to provide needed services at the Hospitals... who:

b. Hold all licenses and certifications, if required by law in order to engage in these respective professions and/or are professionally qualified to provide these services at the Hospitals and Programs as such needed is determined to exist from time to time by the Administration...

e. Meet the qualifications as follows for each of their respective specialties.

Section 2. Psychologists...

... b. Staff Categories for Psychologists:

1. Active Staff

1.1 Qualifications

The active psychology staff shall include licensed psychologists who actively practice psychotherapy or perform psychological evaluations...

... c. Other Affiliate Staff

Other affiliate staff including psychiatric nurse, psychometrists, licensed social workers, and licensed professional counselors credentials are verified via their respective licensure boards...

Review of the Medical Staff Bylaws Appendix I, Rules and Regulations revealed the following:

... These rules and regulations are incorporated by reference into the Medical Staff Bylaws. They are intended to clarify standards of professional practice and the conditions of appointment to the Medical Staff...

... 2.0 Criteria for Admission

2.1 Each physician must accept the criteria for admission to the Hospital and to each program as approved by the Medical Staff and the Board of Directors. These criteria are identified in the Hospital's Utilization Review Plan and in each program description. Waiver of any of these criteria must be approved by the Chief Medical Officer...

... 2.3 The Hospital, through the Chief Medical Officer, has the authority to determine the appropriateness of admissions to a free standing psychiatric facility based on clinical practice guideline.

3.0 Admission

3.1 Patients may be admitted to the Hospital only by licensed Independent Practitioner (LIP) with Medical Staff privileges. All admissions to the Hospital must meet the Hospital's admission criteria as defined in the Hospital's Utilization Management Plan.

... 10.0 Medical Alternate

... 10.2 In an emergency when an appropriate member of the Medical Staff or his/her designee is unavailable, the Chief Medical Officer must be contacted and shall have the authority to make provisions for care for the consumer...

11.0 On-Call

11.1 The Chief Medical Officer shall be administratively responsible for maintaining the organization's on-call roster.

11.2 Each Medical Staff member, with the assistance of the Chief Medical Officer, is responsible for arranging adequate medical coverage in his/her absence.

11.3 "On Call" time begins at 4:30 p.m. on Friday and ends at 4:30 p.m. on the following Friday...

... These Bylaws, Rules, and Regulations shall be reviewed at least annually and approved by the Board of Directors..."


Review of the Utilization Management (UM) Program (Undated with no approval date) revealed:

"... Introduction:

... The goal of the UM Program is to maximize achievement of desired outcomes through effective utilization of available resources, minimize barriers to services provision, and ensure that program services meet the needs of the target population.

Utilization management is conducted initially through the CarePointe staff, by the treatment team members at the program level and overseen by the clinical/administrative supervisory staff. Utilization management functions include but are not limited to review and oversight of the following... Admissions to inconsumer (inpatient), Discharges, Lengths of stay, Transfers.

Reviews conduct admission and continued stay reviews based on the application of the Alabama Department of Mental Health standards... MCG Care Guidelines (formerly Milliman Care Guidelines)...

... EastPointe Hospitals Utilization Review

The Utilization Review program provides the structure to ensure that consumers receive services which are medically necessary, in a setting that is appropriate to the severity of their clinical condition, and at a level of care which will provide the intensity of service their physician documents as medially necessary. The MCG guidelines are utilized to determine if a consumer meets criteria to be admitted to inpatient services.

MCG admission criteria:

Treatment is needed due to consumer risk of 1 or more of the following:

- Imminent danger to self is present
- Imminent danger to others is present
- Life-threatening inability to perform self-care activity is present (such as self-neglect with inability to provide for self at lower level of care).
- Major dysfunction in daily living is present (eg, social, interpersonal, occupational functioning impaired) AND management for the symptoms at highest nonresidential level of care has failed or is not feasible (eg, lower level of care is unavailable or inappropriate)
- Severe problem with cognition, memory, judgment, or impulse control is present AND management for the symptoms at highest nonresidential level of care has failed or is not feasible (eg, lower level of care is unavailable or inappropriate).
- Severe psychiatric symptoms are present (eg, hallucinations, delusions, other acute psychotic symptoms, mania, extreme agitation or anxiety), AND management for the symptoms at highest nonresidential level of care has failed or is not feasible (eg, lower level of care is unavailable or inappropriate).
- Severe comorbid substance use disorder is present that must be controlled (eg, abstinence necessary) to achieve stabilization of primary psychiatric disorder.

"In" consumer care is appropriate (instead of using a lower level of care) as indicated by 1 or more of the following:

1. Consumer is unwilling to participate in treatment voluntarily and requires treatment (eg, legal commitment) in an involuntary unit.
2. Voluntary treatment at lower level of care is not feasible (eg, very short-term crisis intervention or residential care unavailable or unacceptable for consumer condition)
3. Need for physical restraint, seclusion, or other involuntary control is present (eg, actively violent consumer for whom treatment in an involuntary unit is deemed necessary in accord with applicable medical and legal criteria).
4. Around-the-clock medical or nursing care to address symptoms and initiate intervention is required; specific need is identified.

If the consumer meets admission criteria based on MCG guidelines, a hospital admission referral is forwarded to the AltaPointe on-call physician for approval...

Facility Policy:

Subject: Availability of Emergency Services
Policy #: CTS 4.5
Effective: 7/1/99
Revised: 6/14

Policy:

Emergency services are available to consumers enrolled in programs of AltaPointe Health Systems, Inc (AHS). Emergency services are available 24 hours a day, 7 days a week. During normal business hours (8:00 a.m. to 4:30 p.m. weekdays, for most programs) the program will provide crisis/emergency services for consumers enrolled in that program. The procedures listed below, therefore, generally are needed only after-hours, on weekends and holidays.

Procedure:

... 3... EastPointe Hospital

These programs have appropriate clinical, nursing, and medical staff on-call for the specific program.

In the event of an emergency or crisis, the onsite staff will call the program Supervisor, nurse manager, the physician on-call, and/or the administrator on call for directions.

There is accessibility to a local hospital for emergency care when necessary...

For admissions to... EastPointe Hospitals see AHS P & P (Policy & Procedure) 1.0...

Hospital # 2 Policy:

Subject: CarePointe
Policy #: PE 1.0
Effective: 3/1/2000
Revised: 1/13

Policy:

Referrals or requests for services originate from many different agencies and individuals. AltaPointe Health Systems, Inc (AHS) does not restrict referrals by source... AHS attempts to assist all those who contact us. This may include referrals to other agencies, if we are not the most appropriate service provider.

In general, referrals for services will be directed through CarePointe. This allows for consistent and efficient access to admission. Each program has their own criteria by which they screen and accept new admissions once CarePointe has referred the consumer to the program.

Procedure:

1. General:

The consumer and/or guardian contacts CarePointe and the admission screening is completed telephonically. An initial risk screening is completed to determine if the consumer's primary complaint/problems are routine, urgent or emergent in nature. An appointment is scheduled in the appropriate program according to the risk level (10 days subject to appointment availability - routine, 24 hours - urgent, within 1 hour - emergent). If a referral to a program is deemed inappropriate, referral to another agency will be made. After hours, if needed, a crisis staff person completes a crisis report telephonically and makes the appropriate referrals. (see AHS policy CTS 4.5).

Risk potential will be based on the severity and/or combination of the following:

High Risk (1)
Symptoms of Acute Mental Illness
Suicidal or Homicidal
Court evaluation
Pregnant and substance abuser

Moderate Risk (2)
History of multiple psychiatric admissions
Substance abuse by history
History of suicide attempt(s)
No immediate threat to self/other
History of suicide attempts

Low Risk (3)
No previous psychiatric history
No history of suicidal attempts
No psychosis or severe mood disorder
History of psychiatric illness, stable on medications...

6. In some cases either more information is needed, or a slightly different procedure prevails:

... d... EastPointe Hospitals

Admissions to the hospitals will be facilitated by the CarePointe department.

After-hours and weekend admissions are as follows:

1) Based on the information given to the answering service, the consumer is connected to an after hours crisis staff member.

2) If the consumer is suicidal/homicidal or has serious somatic concerns, a referral for hospitalization at ... EastPointe may be facilitated.

3) If an admission is unable to be accommodated, the caller is referred to the nearest ER (Emergency Room) or instructed to call 911.

4) Crisis follow-up:

Crisis reports for active consumers, child or adult, are faxed by the... Crisis and Hospital Coordination Specialist to the attending practitioner, who follows up with the consumer per policy and procedure.

Crisis reports for inactive/new consumers, child or adult, are addressed by the Crisis and Hospital Coordination Specialist, who follows up with the consumer/caller if requested per the crisis report the following business day...


Hospital # 2: Policy

Subject: Pre-Hospitalization Screening
Policy #: PE 1.5
Effective: 1/1/00
Revised: 6/15

Policy:
Consumers who are assessed as needing hospitalization and whose clinical presentation indicates decompensation and instability will be assessed for possible admission to a higher level of care (i.e., crisis stabilization, acute inpatient care).

Procedure:

1. Any AHS clinician (M.D.{Medical Doctor}/ CRNP {Certified Registered Nurse Practitioner}, nurse, therapist) determining that a consumer may require a more intensive level of care will document appropriately.

2. The AHS clinician (M.D./CRNP, nurse, therapist) or other referral source referring to... EastPointe, will contact CarePointe.

3. CarePointe responsibilities include, but are not limited to the following:

a. Complete hospital screening and/or referral electronic forms
b. Verify medical stability and consumer's agreement for voluntary admission (unless otherwise noted)
c. Apply Inpatient Behavioral Health Level of Care Milliman Care Guidelines (MCG) and confirm that the consumer meets admission criteria
d. Check bed availability
e. Complete referral disposition
f. Notify the appropriate hospital of the referral
g. Notify the referral source of the disposition

4. If the consumer is being referred from a medical facility, CarePointe will facilitate the receipt of the following, but not limited to, records:
a. Face sheet
b. Current nursing or physician consultation and progress notes indicating the need and reason for acute psychiatric hospitalization
c. Current medications
d. Vital signs
e. UDS (Urine Drug Screen) and labs
f. CT (Computed tomography) scan results and blood alcohol level if applicable

5. The attending physician or on call practitioner will review the received medical records as appropriate for admission appropriateness...


Hospital # 2 Policy:

Subject: Transfer of Consumers not Meeting Admission Criteria and Unavailability of Beds
Policy #: CTS 5.4
Effect: 5/27/01
Revised: 6/12

Policy:
To ensure optimal consumer care for medically unstable consumers presenting for admission, an assessment will be performed to determine medical status and the hospitals capacity to treat. The hospital will treat consumers based upon the following:
admission criteria, specific needs of the consumer, ability to staff appropriately.

Procedure:

Voluntary:
At the time of admission a Registered Nurse will perform an assessment. If the consumer is deemed to be medically unstable the physician is notified for further evaluation and/or medical orders...


Patient medical record documentation review:

1. PI # 18
PI # 18 presented to Hospital # 1's ED on 2/11/16 at 5:45 PM via ambulance with chief complaint of Psychiatric Evaluation.

Review of the physician's documentation at 8:54 PM revealed the patient's history of present illness included: "... Patient is a 62 y.o. (year old) male presenting with mental health disorder. The history is provided by the patient... The primary symptoms do not include dysphoric mood or negative symptoms. This is a new problem. The onset of the illness is precipitated by a stressful event. The degree if incapacity that he is experiencing as a consequence of his illness is moderate. Sequelae of the illness include homelessness and an inability to work. Additional symptoms of the illness include anhedonia (inability to feel pleasure), agitation and feelings of worthlessness. Additional symptoms of the illness do not include no fatigue, no decreased need for sleep, no headaches or no abdominal pain. He admits to suicidal ideas. He does not have a plan to commit suicide. He does not contemplate harming himself. He has not already injured self. He does not contemplate injuring another person. He has not already injured another person. Risk factors: cancer..."

PI # 18's Physical exam was completed with review of systems, which were unremarkable with the exception of Musculoskeletal system, which included tenderness (acute on chronic L4 - lumbar spine 4 right distribution and the Psychiatric examination, which included, "... Judgement normal. He exhibits a depressed mood. He expresses suicidal ideation. He expresses suicidal plans..."

Review of the Urine Drug screen lab results revealed the patient was positive for cocaine. All other components were within normal limits.

Review of the Urinalysis lab results revealed the patient had a trace of Ketones (Normal for this facility negative). All other components were within normal limits.

Review of the CBC (Complete blood count) lab results revealed the following abnormals: WBC (White blood count) 11.3 (high), Hemoglobin 13.7 (low), MCV (Mean corpuscular volume) 100 (Normal for this facility 82 - 98), MCH (Mean corpuscular hemoglobin) 32 (Normal for this facility 26 - 31), Lymphocytes - Automated 9 (Normal for this facility 20 - 40 %), Neutrophils Absolute 10.09 (Normal for this facility 1.8 - 7.0) and Lymphocytes Absolute 0.96 (Normal for this facility 1.0 - 4.8). All other component were within normal limits.

Review of the ED Notes dated 2/11/16 revealed the RN (registered Nurse) documented the following:

5:59 PM - "... Called Pt (patient) to Triage. No response from waiting area..."

6:55 PM - "... (PI # 18) signed in after discharge from ER (Emergency Room) for back pain; pt states he is now "going to shoot myself"

7:28 PM - "... Psych Consult: pt presented to ER after visiting fast trac (less emergent area of this facility's ED); pt past hx (history) of back pain and depression; pt returned from Fast Track stating that "I will just go home and shoot myself"; pt states that he has been having depression issues since he has had back pain; pt has been having trouble sleeping and his back has been hurting so much he cannot sleep; threatening to harm himself with a gun; pt denies H/I (homicidal ideation) and A/V (audio/visual) hallucinations; case discussed with MD..."

8:59 PM - "Pt medically cleared for transport to inpatient psych facility per Dr (Name)."

9:15 PM - "Pt chart faxed to Care Pointe; awaiting return call"

Review of the ED Orders revealed PI # 18 received Toradol 60 mg (milligrams) injection and Ativan 1 mg. orally at 9:17 PM.

(Toradol (Ketorolac) is a nonsteroidal anti-inflammatory drug (NSAID). Ketorolac works by reducing hormones that cause inflammation and pain in the body. Ativan (lorazepam) is a benzodiazepine and is used to treat anxiety disorders. www.drugs.com)

Review of the ED Notes dated 2/11/16 revealed the RN documented the following:

9:48 PM - "Pt chart faxed to Care Pointe; awaiting return call"

9:49 PM - "Call placed to Care Pointe; they received chart will return call"

10:00 PM - "Pt resting in room; no distress noted; no needs voiced; will monitor"

10:17 PM - "Care Pointe called and they are "unable to accommodate" per (Employee Identifier {EI} # 8, Crisis - Hospital Intake Specialist) RN"

Review of the ED Notes dated 2/12/16 revealed the RN documented the following:

12:15 AM, 2:00 AM and 4:04 AM the patient was resting in the room; no distress or needs.

7:16 AM - "(PI # 18) in room sleeping. Patient slept through the night per night shift nurse. Spoke with the patient asked him if he was still having thought to harm himself. Patient states "I thought you were going to send me to Baldwin County. Informed patient they were unable to accommodate him at this time. Patient was asked about his use of cocaine. Patient states he used cocaine when he went to Mardi Gras and does not have a substance abuse problem. Patient was asked if he still was having thoughts to harm himself. "I need something for my depression, I need something for my nerves, I need something to help me sleep. You come in here talking to me I haven't had my coffee. I haven't washed my face" Patient was asked if he has ever attempted suicide in the past. Patient stated "I put a gun to my head last year" Patient stated he has never seen a psychiatrist or went to get any help for his depression in the past. No psychosis noted. Patient denies auditory and visual hallucinations. Patient continues to request in-patient psychiatric treatment..."

8:00 AM - "Patient comes out of room and is belligerent states "can I go to the bathroom... " Patient is demanding and appears to be seeking secondary gain..."

Review of the ED Events revealed the patient was set for discharge by the ED physician at 8:29 AM on 2/12/16.

Review of the ED Notes dated 2/12/16 at 9:13 AM revealed the RN documented, "Patient discharged per MD. Patient spit multiple times on the floor. When asked not to do that the patient states... You didn't get me any tissues... Box of tissues sitting on his bedside table. Patient requested two bus passes. One was provided and he was escorted to front of ER by security..."

PI # 18 was discharged on 2/12/16 at 9:17 AM in stable condition with discharge instructions.
Review of records obtained from EastPointe / Hospital # 2:

Review of the Fax Transmittal Cover Sheet from Hospital # 1 revealed the documents, which included PI # 18's medical record information from Hospital # 1 were sent to CarePointe on 2/11/16 at 9:05 PM.

Review of the Care Pointe Call Intake documentation dated 2/11/16 at 10:00 AM revealed EI # 8, Crisis - Hospital Intake Specialist documented, "... (Hospital # 1) seeking inpatient treatment for consumer with chronic back pain and situational suicidal ideation. Consumer presented to the ER by EMS (Emergency Medical Services) with complaints of back pain (3 surgeries in 5 years) and requests IV (intravenous) morphine and MRI (Magnetic resonance Imaging). Consumer was also positive for cocaine. After discharge was recommended and consumer was offered a taxi voucher, he reported he is now "going to shoot myself". Consumer refused to sign his discharge paperwork. Writer consulted (EI # 12, EastPointe {Hospital # 2} Psychiatrist), on-call physician. Not approved for transfer to Hospital # 2 /EastPointe Hospital..."

Review of the Pre-Intake Information dated 2/11/16 at 10:22 PM revealed EI # 8 documented, (PI # 18) "... Status of Consumer: New... What prompted you to call today? (Hospital # 1) seeking inpatient treatment for consumer with chronic pain and questionable SI (suicidal ideation). Consumer is positive for cocaine and is requesting IV (intravenous) (morphine). Dr. (EI # 12, Hospital # 2 Psychiatrist) did not approved transfer to Hospital # 2 /EP (East Pointe)... Hospital Screening... Did a NON-AHS professional (doctor, therapist etc) recommend EP... hospital services?: Yes If so, who referred you? (ED physician) at (Hospital # 1)... Symptoms/Risk Factors Reported: Suicidal Ideation/ Current, Use of Alcohol or drugs. If PLAN or ideations, please list HOW RECENT OR IF CURRENT, means, when, who, etc: SI reported today after consumer was asked to leave the hospital... Date of last thought(s) or attempts(s): SI reported today - with intent of secondary gain...Presenting Problem and/or General Admission Criteria (include precipitating factors or event(s) that led to/prompted crisis: (Hospital # 1) seeking inpatient treatment for consumer with chronic back pain and situational suicidal ideation. Consumer presented to the ER by EMS with complaints of back pain (3 surgeries in 5 years) and requests IV morphine and MRI. Consumer was also positive for cocaine. After discharge was recommended and consumer was offered a taxi voucher, he reported he is now "going to shoot myself". Consumer refused to sign his discharge paperwork. Writer consulted (EI # 12- Hospital # 2 Psychiatrist), on-call physician. Not approved for transfer to EastPointe Hospital (Hospital # 2) ..."

Review of the AltaPointe Health Systems, EastPointe Hospital Consumer list dated 2/11/16 revealed there were 33 consumers admitted to Hospital # 2, 15 of which were voluntary consumer admissions. This meant Hospital # 2 had a total of 33 hospital beds, 21 of which were designated for voluntary patients available to admit PI # 18.



18555

2. PI # 15
Review of Altapointe's (Referral Intake Center for EastPointe Psychiatric Hospital - Hospital # 2) Pre-Intake Information regarding PI #15 by EI # 7, CarePointe Specialist:

Call Type: Hospital Screening
Call Time: 9:25 AM
Client Name: PI # 15
Caller Name: PI # 15's family member
Caller Comments: Consumer (PI # 15) is having thoughts of hurting others, is being violent at his place of employment. Threatening his coworkers and bosses with violent behavior. Experiencing severe mood swings and suicidal ideation. He is not taking his medications.

Review of the Call Intake 1/20/16 by EI # 7, CarePointe Specialist :

Call Time: 9:50 AM

Comments: "Contacted (name of PI # 15's family member) about the possibility of calling 911 for consumer (PI # 15) to be transported to the nearest ER (Emergency Room) for evaluation. She texted the consumer who responded that he gives permission to be transported to the ER..."

Review of the Call Intake 1/20/16 by EI #7, CarePointe Specialist:

Call Time: 10:05 AM

Comments: "Contacted the consumer's (PI # 15) ex-spouse...to discuss safety issues with her regarding the consumer. Inquired about consumer being at home alone. She stted (stated) that he is alone at this time. Informed her that since he is alone, she should call 911 to have him transported to the nearest ER to be evaluated. Explained that the ER can contact this agency about a transfer to EastPointe (Hospital # 2)...(name of ex spouse) to contact 911."

ED Physician Documentation faxed from Hospital # 3 (Transferring Hospital - does not provide inpatient psychiatric treatment) to Hospital # 2, requesting inpatient treatment for PI # 15:

Arrival Date: 1/20/16
Time: 11:26 AM
HPI (History of Present Illness): 42 year old male presents to the Emergency Department with depression over unknown circumstances. Symptoms began gradually. Prior diagnoses: history of substance abuse alcohol, generalized anxiety disorder. It is unknown whether or not the patient has had a prior suicide attempt. Positive for episodes of aggressive behavior.

Patient states he historically, "Gets depressed when it gets cold." Patient specified that he has been, "Getting manic," and symptoms have lead to violent behavior involving abuse of his dog.

Home medications:
1. Clonazepam (dosage unknown) 1 tab as needed.
2. Effexor 75 milligrams (mg.) daily.
3. Abilify 30 mg. daily for Depression treatment adjunct.

Medical History: Anxiety, Antisocial Disorder; unspecified, Cannabis abuse with cannabis induced anxiety disorder, Alcohol Intoxication; Non-dependent, Recovering Alcoholism with recent binge.

Examination:
PI # 15 appears in no acute distress. Alert, awake and "uncomfortable." Cranial nerves grossly normal. Behavior/mood is anxious, depressed. Affect flat. Patient has no thoughts/intents to harm self/others.

Vital Signs: 1/20/16 11:30 AM: 132/85, 92, 20, 98.1

Differential diagnoses: Acute Psychotic Break, Acute Anxiety Disorder, Depression, Drug -Induced Psychosis secondary to non-compliance, Suicidal Ideation.

Urine Drug Screen: Normal. Alcohol/Acetaminophen/Aspirin: Normal.
Complete Blood Count with Differential: Normal except WBC (White Blood Cells): 10.4 (High; Range 5.0-10.0); Hemoglobin ( protein in red blood cells that carries oxygen throughout the body): 16.8 (High; Range 12.6 -15.0).

1/20/16 at 2:21 PM: Medically cleared for admission.


Review of the Call Intake dated 1/20/16 by EI #7 , CarePointe Specialist, revealed the following:

Call Time: 11:35 AM

Comments: Staff from Hospital # 3 (Referring Hospital) called in gain collateral on the consumer (PI # 15) who states that he has a bed reserved at Eastpointe ( Hospital # 2, Free Standing Psychiatric Facility). Staff informed that he was "approved for a screening" but was having homicidal ideations towards his coworkers, was agitated and unsafe to transport by own self. She (Hospital # 3- Referring Facility) Staff was informed they (Hospital # 3) would need to facilitate this patient (PI # 15) as a transfer... and complete labs for the doctors at EastPointe to ensure medically clear.

Review of AltaPointe's Health System's "Inpatient Hospitalization Referral Fax (facsimile) Cover Sheet" from Hospital # 3 (Transferring Hospital) dated 1/20/16 at 2:37 PM and clinical information transmitted via (fax) to Hospital # 2 includes:

Do consumer and/or guardian agree to voluntary psychiatric admission? Yes

Is the consumer medically clear and stable? Yes

For inpatient hospitalization, please fax the required paperwork:
1. Inpatient Hospitalization Request fax cover sheet.
2. Consumer (patient) demographics: (include... "insurance policy.)"
3. Medications currently prescribed.
4. Most recent set of vital signs.
5. Completed lab results for CBC, UDS (Urine drug screen)and Chem (chemistry) Profile.
6. Written medical clearance.
7. Current blood alcohol level (if applicable).
8. Current Tylenol level (if applicable).
9. AltaPointe physician's psychiatric consultation (if applicable).
10. Current nursing/physician notes. Note: Documentation should be dated for the same day as the referral indicating the specific reason for the acute psychiatric hospitalization...
11. Current treatment notes or consultation.

Reason for seeking inpatient psychiatric care:

Suicidal with a plan / Suicidal without plan or Homicidal with a plan / Homicidal without plan (answer not documented)

Psychotic Symptoms or Other (please explain) (answer not documented)

Review of the Call Intake 1/20/16 by EI # 1, Hospital Admission and Referral Specialist, CarePointe:

Call Time: 4:15 PM

Comments: Hospital referral received from Hospital # 3.

Review of the Call Intake 1/20/16 by EI # 1:

Call Time: 4:35 PM

Comments: EI #1, CarePointe Hospital Admission and Referral Specialist, notified by Hospital Clinical Coordinator (Hospital # 2), that based on the information from Hospital # 3 (Referring Hospital), PI # 15 will not be accepted to EastPointe / Hospital # 2. Symptoms appear to be personality or substance induced per MD (psychiatrist at Hospital # 2) Writer (EI# 1) notified Clinical Coordinator that patient reported thoughts of harming people at his job this AM. The Coordinator stated Hospital # 3 would need to send documentation of this if patient is to be considered at EP. Writer (EI #1) notified Case Manager at (Hospital # 3) that patient does not meet admission criteria based on the information provided.

Review of the Call Intake 1/20/16 by EI #8, Crisis - Hospital Specialist Intake Center for Hospital # 2:

Call Time: 5:20 PM

Comments: "Patient's (PI # 15) wife called seeking

Based on review of Bylaws of the Medical Staff, Medical Staff Bylaws Appendix I, Rules and Regulations, policies and procedures, Utilization Management Program, AHS (AltaPointe Health Systems) After Hours Crisis Contact Log, medical records, AltaPointe Health Systems, EastPointe Hospital Consumer lists and interviews with facility staff, it was determined the facility failed to ensure the psychiatrists receive/review all Emergency Department transfer requests for inpatient treatment and accept medically stable consumers (patients) who required psychiatric inpatient treatment to stabilize their psychiatric conditions, which the facility had the capability and capacity to treat from referring hospitals' emergency departments. This affected 8 of 43 records reviewed, including Patient Identifier (PI) # 1, 14, 16, 17, 19, 11, 12 and 13 emergency department requests of patients appropriate for transfer to EastPointe Psychiatric Hospital, which had the capacity and capability to treat the patients.

Findings include:

Review of the Bylaws of the Medical Staff revision date 10/14, revealed the following... Whereas, one of the primary goals of the Medical Staff is to provide consumer care commensurate with each consumer's individual need, the Medical Staff must work with the Chief Executive Officer and is subject to policies and disciplinary standards as necessary to fulfill the goals and objectives of AltaPointe Health Systems, Inc. in providing optimum quality of care to its consumers; and,

Therefore, licensed independent practitioners (LIP) practicing in this community mental health organization organize themselves into a Medical Staff in conformity with these Bylaws.

The Bylaws, when adopted by the Governing Body, create a mutually binding agreement between the Medical Staff and governing body, which may not be unilaterally amended...

Definitions:

The following definitions apply to the provisions of these Medical Staff Bylaws and its related manuals...

3. Affiliate Staff shall mean that organizational component of the Hospitals and Programs comprised of all non-physician staff to include psychiatric nurses, psychometrists, licensed social workers and licensed professional counselors...

12. Licensed Independent Practitioner (LIP) shall mean an individual permitted by law and by the organization to provide care and services, without direction or supervision, within the scope of the individual's license and consistent with individually granted clinical privileges. At AltaPointe, such individuals include: MD (Medical Doctor), DO (Doctor of Osteopathy), Certified Nurse Practitioner, and a Physician Assistant.

13. Medical Staff or Staff shall mean that component of the company's organizational chart that stands for all practioners as defined below who are appointed to membership and are privileged to attend consumers or to provide diagnostic, therapeutic, services at the organization...

Article I. Purpose and Responsibility

Section 1. Purpose.

The purpose of the Medical Staff of the Hospitals and Programs shall be:

a. To establish and maintain an appropriate level of professional performance and ethical conduct of each individual authorized to practice his/her profession in the Hospitals and Programs through the credentialing process, the delineation of clinical privileges, and ongoing Peer Review and evaluation, subject to approval of the Board;

b. To provide quality care for consumers admitted to the Hospitals and Programs;

... e. To provide an appropriate medical setting that will maintain scientific standards and foster continuous advancement in professional knowledge and skill;

f. To plan, coordinate and develop the system of behavioral health, intellectual disabilities and substance abuse services for the citizens of Mobile, Washington, Baldwin Counties and other regional catchment areas...

Article II. Medical Staff Membership

Membership of the Medical Staff shall be extended only to competent professional physicians, nurse practitioners, and physician assistants who continuously meet the qualifications and requirements set for in these Bylaws....

Section 2. Basic Qualifications for Membership.

Only a physician, nurse practitioner or physician assistant licensed to practice in the state of Alabama shall be eligible for membership in the Medical Staff who continuously meets the following requirements and is able to fully document, demonstrate, and/or produce all the following to the satisfaction of the appropriate representatives of the Medical Staff and Board:

a. Current unrestricted license to practice medicine in the State of Alabama...

b. Educational background, including graduation from a school of medicine, osteopathy, or graduation from an accredited school of nurse practitioner...

f. Current clinical experience and results and utilization practice patterns, and continuing ability to provide appropriate, quality, and efficient consumer care services within available resources...

h. Current permit form the Drug Enforcement Administration (DEA) and current State narcotic license to prescribe controlled substances...

Article III. Categories and Privileges of the Medical Staff

... Section 2. Psychiatric Staff

a. Active

1. Qualifications: The active psychiatric staff shall consist of physicians who are eligible or board certified in psychiatry... certified nurse practitioners (CRNP) who are licensed by the Alabama Board of Nursing and Physician Assistant licensed by the Alabama Board of Medical Examiners and regularly involve in the care of psychiatric consumers at the Hospitals and Programs, each of whom meets the basic qualifications set forth herein:

1.1 Resides and practices psychiatry in adequate proximity to the Hospitals and Programs to provide continuous psychiatric care and supervision to his/her consumers.

1.2 Regularly admits or rounds at more than eighteen per year to the Hospitals...

... e. Non-psychiatric Staff

1. Consulting Staff

1.1 Qualifications:
The consulting non-psychiatric staff consist of LIPs who are not psychiatrists and who are involved in the care of psychiatric consumers at the Hospitals and Programs. These individuals do not have admitting privileges. Each shall:

1.2 Meet the requirements for membership as set forth herein...

... 2. Privileges and Prerogatives: The non-psychiatric consulting staff shall be privileged and credentialed according to the requirement set forth below.

2.1 Physicians who are granted privileges shall have completed an accredited residency program within their area of specialization. Physicians with privileges may provide emergency and follow-up care...

f. Change in Category of Non-Psychiatric Medical Staff

Changes within the categories of non-psychiatric medical staff may be initiated by the submission of the appropriate credentials to the CMO (Chief Medical Officer) who shall collect and verify the information and shall submit this request along with the proper documentation to the Medical Staff Committee regarding the requested change. The Medical Staff Committee shall submit a recommendation to the Board. Such changes in categories will be processed and will be subject to the limitations imposed for initial appointment to the psychiatric medical staff as applicable...

Article IV. Active Categories and Privileges of the Affiliate Staff

Section 1. Active Affiliate Staff

a. Qualifications: Affiliate staff duties and privileges are subject to the bylaws, Rules and Regulations and policies, and policies of the Hospitals and Programs, and the applicable federal and state laws and regulations. Such duties and limitations must be performed with due prudence and demonstrated proficiency. Affiliate Staff designation may be extended to nurses with psychiatric training, counselors, psychologists, social workers, psychometrists, and other individuals specified herein who are professionally qualified to provide needed services at the Hospitals and Programs who:

b. Hold all licenses and certifications, if required by law in order to engage in these respective professions and/or are professionally qualified to provide these services at the Hospitals and Programs as such needed is determined to exist from time to time by the Administration.

c. Propose to provide services in one or mote patient care areas of the Hospitals and Programs that are equipped, staffed and licensed to offer this care to patients...

e. Meet the qualifications as follows for each of their respective specialties.

Section 2. Psychologists.

a. Qualifications: Minimum qualifications include;

1. Criteria for persons receiving the doctoral degree in Psychology in 1981 or after, shall be:

1.1 A doctoral degree in clinical counseling or medical psychology from and APA (American Psychological Association) approved program, and

1.2 An APA approved internship, and

1.3 A license issued by the Alabama Board of Examiners in Psychology; or

1.4 A diplomat of the American Board of Professional Psychology, and

1.5 A license issued by the Alabama Board of Examiners in Psychology, or

1.6 A Re-specialization Certificate in clinical counseling or medical psychology and an APA approved internship, and

1.7 A license issued by the Alabama Board of Examiners in Psychology.

2. Criteria for persons receiving the doctoral degree in Psychology prior to 1981 shall be:

2.1 Completion of a doctoral degree in clinical counseling or medical psychology from a regionally accredited university, and

2.2 Completion of a doctoral dissertation or other requirement of the program in lieu of dissertation that is primarily psychology in nature, either pre or post-doctoral, and

2.3 Completion of a full-time, one year long internship in a clinical setting and

2.4 A license issues by the Alabama Board of Examiners in Psychology

2.5 A diplomat of the American Board of Professional Psychology, and

2.6 A license issued by the Alabama Board of Examiners in Psychology.

b. Staff Categories for Psychologists:

1. Active Staff

1.1 Qualifications

The active psychology staff shall include licensed psychologists who actively practice psychotherapy or perform psychological evaluations. The applicant must show evidence of competence in the areas to which he/she applies (psychotherapy and/or psychological evaluations) and satisfactory standing in the professional community of psychologists as evidenced by the application materials and letters of reference...

c. Other Affiliate Staff

Other affiliate staff including psychiatric nurse, psychometrists, licensed social workers, and licensed professional counselors credentials are verified via their respective licensure boards.


Review of the Medical Staff Bylaws Appendix I, Rules and Regulations revealed the following:

... These rules and regulations are incorporated by reference into the Medical Staff Bylaws. They are intended to clarify standards of professional practice and the conditions of appointment to the Medical Staff...

... 2.0 Criteria for Admission

2.1 Each physician must accept the criteria for admission to the Hospital and to each program as approved by the Medical Staff and the Board of Directors. These criteria are identified in the Hospital's Utilization Review Plan and in each program description. Waiver of any of these criteria must be approved by the Chief Medical Officer.

2.2 Physicians are responsible for giving such information prior to admission as may be necessary to establish that the consumer meets all admission criteria and to promote the safety of the consumer and that of other consumers in the Hospital.

2.3 The Hospital, through the Chief Medical Officer, has the authority to determine the appropriateness of admissions to a free standing psychiatric facility based on clinical practice guideline.

3.0 Admission

3.1 Patients may be admitted to the Hospital only by licensed Independent Practitioner (LIP) with Medical Staff privileges. All admissions to the Hospital must meet the Hospital's admission criteria as defined in the Hospital's Utilization Management Plan.

3.2 Except in an emergency, a provisional or admitting diagnosis must be made on every consumer at the time of admission, and must include the diagnosis of inter-current disease as well as the psychiatric diagnosis...

... 10.0 Medical Alternate

... 10.2 In an emergency when an appropriate member of the Medical Staff or his/her designee is unavailable, the Chief Medical Officer must be contacted and shall have the authority to make provisions for care for the consumer...

11.0 On-Call

11.1 The Chief Medical Officer shall be administratively responsible for maintaining the organization's on-call roster.

11.2 Each Medical Staff member, with the assistance of the Chief Medical Officer, is responsible for arranging adequate medical coverage in his/her absence.

11.3 "On Call" time begins at 4:30 p.m. on Friday and ends at 4:30 p.m. on the following Friday.

12.0 Consultations...

13.0 Utilization Review

The Medical Staff is required to document the need for admission and for continued hospitalization. Utilization reviews are scheduled on a systematic basis according to the Utilization Review Plan of the Hospital as approved by the Board of Directors...

17.0

These Bylaws, Rules, and Regulations shall be reviewed at least annually and approved by the Board of Directors..."


Review of the Utilization Management Program (Undated with no approval date) revealed:

"... Introduction:

The AltaPointe Health System, Inc Utilization Management (UM) Program was developed to ensure efficient service delivery and management of organization resources in order to provide high quality, cost-effective behavioral health care to our target population.

The goal of the UM Program is to maximize achievement of desired outcomes through effective utilization of available resources, minimize barriers to services provision, and ensure that program services meet the needs of the target population.

Utilization management is conducted initially through the CarePointe staff, by the treatment team members at the program level and overseen by the clinical/administrative supervisory staff. Utilization management functions include but are not limited to review and oversight of the following... Admissions to inconsumer (inpatient), Discharges, Lengths of stay, Transfers.

Reviews conduct admission and continued stay reviews based on the application of the Alabama Department of Mental Health standards... MCG Care Guidelines (formerly Milliman Care Guidelines)...

... EastPointe Hospitals Utilization Review

The Utilization Review program provides the structure to ensure that consumers receive services which are medically necessary, in a setting that is appropriate to the severity of their clinical condition, and at a level of care which will provide the intensity of service their physician documents as medially necessary. The MCG guidelines are utilized to determine of a consumer meets criteria to be admitted to inpatient services.

MCG admission criteria:

Treatment is needed due to consumer risk of 1 or more of the following:

- Imminent danger to self is present
- Imminent danger to others is present
- Life-threatening inability to perform self-care activity is present (such as self-neglect with inability to provide for self at lower level of care).
- Major dysfunction in daily living is present (eg, social, interpersonal, occupational functioning impaired) AND management for the symptoms at highest nonresidential level of care has failed or is not feasible (eg, lower level of care is unavailable or inappropriate)
- Severe problem with cognition, memory, judgment, or impulse control is present AND management for the symptoms at highest nonresidential level of care has failed or is not feasible (eg, lower level of care is unavailable or inappropriate).
- Severe psychiatric symptoms are present (eg, hallucinations, delusions, other acute psychotic symptoms, mania, extreme agitation or anxiety), AND management for the symptoms at highest nonresidential level of care has failed or is not feasible (eg, lower level of care is unavailable or inappropriate).
- Severe comorbid substance use disorder is present that must be controlled (eg, abstinence necessary) to achieve stabilization of primary psychiatric disorder.

In consumer care is appropriate (instead of using a lower level of care) as indicated by 1 or more of the following:

1. Consumer is unwilling to participate in treatment voluntarily and requires treatment (eg, legal commitment) in an involuntary unit.
2. Voluntary treatment at lower level of care is not feasible (eg, very short-term crisis intervention or residential care unavailable or unacceptable for consumer condition)
3. Need for physical restraint, seclusion, or other involuntary control is present (eg, actively violent consumer for whom treatment in an involuntary unit is deemed necessary in accord with applicable medical and legal criteria).
4. Around-the-clock medical or nursing care to address symptoms and initiate intervention is required; specific need is identified.

If the consumer meets admission criteria based on MCG guidelines, a hospital admission referral is forwarded to the AltaPointe on-call physician for approval...

Facility Policy:

Subject: Availability of Emergency Services
Policy #: CTS 4.5
Effective: 7/1/99
Revised: 6/14

Policy:

Emergency services are available to consumers enrolled in programs of AltaPointe Health Systems, Inc (AHS). Emergency services are available 24 hours a day, 7 days a week. During normal business hours (8:00 a.m. to 4:30 p.m. weekdays, for most programs) the program will provide crisis/emergency services for consumers enrolled in that program. The procedures listed below, therefore, generally are needed only after-hours, on weekends and holidays.

Procedure:

... 3... EastPointe Hospital

These programs have appropriate clinical, nursing, and medical staff on-call for the specific program.

In the event of an emergency or crisis, the onsite staff will call the program Supervisor, nurse manager, the physician on-call, and/or the administrator on call for directions.

There is accessibility to a local hospital for emergency care when necessary...

For admissions to... EastPointe Hospitals see AHS P & P (Policy & Procedure) 1.0...

Facility Policy

Subject: CarePointe
Policy #: PE 1.0
Effective: 3/1/2000
Revised: 1/13

Policy:

Referrals or requests for services originate from many different agencies and individuals. AltaPointe Health Systems, Inc (AH) does not restrict referrals by source... AHS attempts to assist all those who contact us. This may include referrals to other agencies, if we are not the most appropriate service provider.

In general, referrals for services will be directed through CarePointe. This allows for consistent and efficient access to admission. Each program has their own criteria by which they screen and accept new admissions once CarePointe has referred the consumer to the program.

Procedure:

1. General:

The consumer and/or guardian contacts CarePointe and the admission screening is completed telephonically. An initial risk screening is completed to determine is the consumer's primary complaint/problems are routine, urgent or emergent in nature. An appointment is scheduled in the appropriate program according to the risk level (10 days subject to appointment availability - routine, 24 hours - urgent, within 1 hour - emergent). If a referral to a program is deemed inappropriate, referral to another agency will be made. After hours, if needed, a crisis staff person completes a crisis report telephonically and makes the appropriate referrals. (see AHS policy CTS 4.5).

Risk potential will be based on the severity and/or combination of the following:

High Risk (1)
Symptoms of Acute Mental Illness
Suicidal or Homicidal
Court evaluation
Pregnant and substance abuser

Moderate Risk (2)
History of multiple psychiatric admissions
Substance abuse by history
History of suicide attempt(s)
No immediate threat to self/other
History of suicide attempts

Low Risk (3)
No previous psychiatric history
No history of suicidal attempts
No psychosis or severe mood disorder
History of psychiatric illness, stable on medications...

6. In some cases either more information is needed, or a slightly different procedure prevails:

... d... EastPointe Hospitals

Admissions to the hospitals will be facilitated by the CarePointe department.

After-hours and weekend admissions are as follows:

1) Based on the information given to the answering service, the consumer is connected to an after hours crisis staff member.

2) If the consumer is suicidal/homicidal or has serious somatic concerns, a referral for hospitalization at ... EastPointe may be facilitated.

3) If an admission is unable to be accommodates, the caller is referred to the nearest ER (Emergency Room) or instructed to call 911.

4) Crisis follow-up:

Crisis reports for active consumers, child or adult, are faxed by the... Crisis and Hospital Coordination Specialist to the attending practitioner, who follows up with the consumer per policy and procedure.

Crisis reports for inactive/new consumers, child or adult, are addressed by the Crisis and Hospital Coordination Specialist, who follows up with the consumer/caller if requested per the crisis report the following business day...

Facility Policy

Subject: Pre-Hospitalization Screening
Policy #: PE 1.5
Effective: 1/1/00
Revised: 6/15

Policy:
Consumers who are assessed as needing hospitalization and whose clinical presentation indicates decompensation and instability will be assessed for possible admission to a higher level of care (i.e., crisis stabilization, acute inpatient care).

Procedure:

1. Any AHS clinician (M.D.{Medical Doctor}/ CRNP {Certified Registered Nurse Practitioner}, nurse, therapist) determining that a consumer may require a more intensive level of care will document appropriately.

2. The AHS clinician (M.D./CRNP, nurse, therapist) or other referral source referring to... EastPointe, will contact CarePointe.

3. CarePointe responsibilities include, but are not limited to the following:

a. Complete hospital screening and/or referral electronic forms
b. Verify medical stability and consumer's agreement for voluntary admission (unless otherwise noted)
c. Apply Inpatient Behavioral Health Level of Care Milliman Care Guidelines (MCG) and confirm that the consumer meets admission criteria
d. Check bed availability
e. Complete referral disposition
f. Notify the appropriate hospital of the referral
g. Notify the referral source of the disposition

4. If the consumer is being referred from a medical facility, CarePointe will facilitate the receipt of the following, but not limited to, records:
a. Face sheet
b. Current nursing or physician consultation and progress notes indicating the need and reason for acute psychiatric hospitalization
c. Current medications
d. Vital signs
e. UDS (Urine Drug Screen) and labs
f. CT (Computed tomography) scan results and blood alcohol level if applicable

5. The attending physician or on call practitioner will review the received medical records as appropriate for admission appropriateness...


Record reviews of patients identified:

1. PI # 1
Medical Record Review: Hospital # 1:

ED (Emergency Department) Notes:

Arrival Date/Time: 1/13/16 at 7:59 PM via ambulance.
Triage Time: 8:07 PM
Acuity: Urgent.
Chief Complaint: Psychiatric Evaluation

1/13/16 at 8:09 PM: First ED Note by Registered Nurse (RN): Patient ( PI # 1) arrived via stretcher from Walmart parking lot. EMS (Emergency Medical Services) states PI # 1 was walking across the parking lot holding a butcher knife. Per EMS the patient's Mom reports PI # 1 has been off medication and has a psychiatric diagnosis, but she does not know medications or diagnosis. Patient awake, alert, confused to place and time and unable to answer any questions correctly. Patient blurting out random words.

1/13/16 at 9:05 PM: Haldol 5 milligrams (mg.), Benadryl 50 mg. and Ativan 2 mg. injections given to PI # 1.

1/13/16 at 9:35 PM: "Psych consult" by RN: Patient arrives to ER (Emergency Room) per EMS after being found wandering around a parking lot with a knife in hand. Speaking in word salad: "The missiles are there and my head is above them." Appears extremely paranoid, continually scanning the room. Difficulty following simple verbal commands. Responds to internal stimuli. ...UDS (urine drug screen) negative...Case discussed with MD (Medical Doctor).

1/14/16 at 6:19 AM: Spoke with patient's mother. Previous diagnosis of schizophrenia... According to the mother PI # 1 said, "They gone to try to get us but they ain't gone get us. Before I knew it, ... (PI # 1) was outside the parking lot with a butcher knife." Per patient's mother... (PI # 1) has been non-compliant with medications and refuses to seek treatment.

1/14/16 at 7:00 AM: Nursing documentation revealed multiple attempts to find inpatient treatment for PI # 1, but no psych beds were available.

1/14/16 at 8:21 AM: PI # 1 has flight of ideas. Thoughts are loose and disorganized, and is responding to internal stimuli. "Germans and credit cards." Rambles about military bases. Patient cooperative and agrees to transfer to a psychiatric hospital.

Medically cleared by (Hospital # 1's ED Physician). "No beds available" at (Hospital # 1/Referring Hospital).

1/14/16 at 8:50 AM: Patient (PI # 1) pacing rapidly in room. "I need to go to a military base." ... Appears very psychotic. Agrees to take medication.

1/14/16 at 8:55 AM: Haldol 5 mg., Benadryl 50 mg. and Ativan 2 mg. injections given to PI # 1.

1/14/16 at 9:00 AM: Chart faxed to (Call/Referral Center for Hospital # 2).

Review of the Referral for PI # 1 for inpatient psychiatric treatment by (Hospital # 1) Emergency Department Staff to Hospital (Hospital # 2) intake staff:

A review of the AltaPointe Systems, Inc. Hospital Referral Form revealed Patient Identifier (PI) # 1 was referred to EastPointe Psychiatric Hospital (Hospital # 2) for inpatient treatment on 1/14/16 by (Hospital # 1).

1/14/16 at 9:04 AM:

"1. Identification Section:
Hospital use only.. No documentation of legal status (voluntary versus involuntary).
Referral Source: Hospital...
Hospital: (Hospital # 1 - referring hospital).

* No insurance information documented by (Hospital # 1)

2. Symptoms/ Risk Factors: No documentation...

3. Presenting problems and/or General Admission Criteria: Hospital referral received from (Hospital # 1). Hospital # 2) is UTA (unable to accommodate) "SP (Self-pay)/non-intensive."

Verified definition of "SP/non-intensive" during a telephone interview with Employee Identifier (EI) # 12, Director Performance Improvement, at 2:30 PM on 3/23/16 to mean, "Self pay for non-intensive services. The patient (PI # 1) did not require inpatient." The patient could have been treated as an outpatient as determined by the therapist at AltaPointe (Referral/Intake Center for EastPointe Hospital).

6. Prior Psychiatric Hospitalization:
AltaPointe psychiatric history (include previous treatment): None

Name of Physician Consulted: No documentation


Medical Record Review: Hospital # 1:

ED (Emergency Department) Notes:

1/14/16 at 9:15 AM: Received a call from EI # 1, Hospital Admission and Referral Coordinator, Intake Center for Hospital # 2. They are unable to accommodate patient at this time. Per EI #1, "It is not due to availability of beds or clinic appropriateness. It is a company policy... " Clarified with EI # 1 that they (Hospital # 2) do have beds and clinical documentation was appropriate.

1/14/16 at 12:38 PM: Call placed to (Hospital # 2's Hospital's Intake/Referral Center) by (Hospital # 1's) ED staff. It was noticed patient has Medicare. Previous insurance face sheet had no insurance documented. Hospital # 2 asked us (Hospital # 1) to resend face sheet.

1/14/16 at 2:30 PM: Call placed to Hospital # 2's intake center from Hospital # 1. Spoke with EI # 16, Aftercare and Referral Specialist at Hospital # 2, who said, "The doctor has not reviewed the chart." Patient's (PI # 1) thoughts remain loose and disorganized...

1/14/16 at 2:35 PM: ... Chart has not changed since this AM... Only change: "We (Hospital # 1) found out the patient does have insurance."

1/14/16 at 3:00 PM: Received a call from EI # I, "We need to know if the patient is voluntary." Explained PI # 1 is psychotic and is thought blocking. Unable to determine if patient can give consent.

1/14/16 at 3:51 PM: PI # 1 pacing in room (remains in ED at Hospital # 1). Asked patient if he is hearing voices. PI # 1 states, "Not to much. Jamaican. Have you ever been in a helicopter?"

1/14/16 at 4:04 PM: Received a call from EI #1, Admission Referral Coordinator - Hospital # 2's Intake Center, who states, "They (Hospital # 2) are willing to accept the patient (PI #1) on a voluntary basis and if he becomes involuntary at EastPointe then they will be glad to file a petition to hold him..."

1/14/16 at 4:27 PM: Sheriff here from probate court. Patient (PI # 1)discharged to sheriff.

A review of the AltaPointe Systems, Inc. Hospital Referral Form dated 1/14/16 at 5:04 PM revealed:

1. Identification Section:
Hospital use only...Voluntary
Referral source: Hospital
Hospital: (Hospital # 1/Referring Hospital)...

Insurance Information:

Does the consumer (patient) have insurance? Yes

Insurance Provide: Medicare

Does the consumer have secondary insurance? Yes

Insurance Provider: Medicaid...

... 2. Symptoms/Risk Factors:
"Agitation, aggression, assault. Current history of med (medication) non-compliance. Delusions or hallucinations, Mental illness symptoms worsening,... Neglecting daily responsibilities, Poor coping skills..." (meaning unknown)

If hallucinating, delusional or COMMAND hallucinations, please specify: Consumer (PI # 1) arrived to the ED by ambulance on 1/13/16. Consumer's (Patient's) mother called 911 after consumer was found walking around the Walmart parking lot holding a butcher knife stating, "The missiles are there and my head is above them." PI # 1 is extremely paranoid and disorganized. His mother reports that PI # 1 has a past diagnosis of paranoid schizophrenia, but has been noncompliant with meds (medications) and treatment since moving here from Ohio seven months ago. PI # 1 is agreeable to be transferred to a psychiatric hospital.

Review of Hospital # 1's ED Physician Documentation:

1/14/16 at 5:44 PM: This case is a certified medical emergency.

HPI (History of Present Illness): Limited by patient condition. Patient (PI # 1) arrives to ER after being found wandering around a parking lot with a knife in his hands. Speaking in word salad. Appears extremely paranoid. Difficulty following simple verbal commands. Responds to internal stimuli...

Physical Examination: BP (Blood pressure): 138/80, Pulse: 99, Temp: 98.6, Resp (respirations): 20

PI # 1 appears well developed and well nourished.
Head: Normocephalic and atraumatic.
ENT (Ears, Nose, Throat): Normal
Eyes/Neck: PERRL (Pupils equal, round, reactive to light). Normal ROM (Range of Motion).
Cardiovascular: Normal rate and rhythm.
Pulmonary: Breath sounds normal.
Abdominal: Soft. Bowel sounds normal.
MSK (Musculoskeletal): Normal ROM.
Neuro (Neurological): Normal reflexes. No cranial nerve deficit.
Skin: Warm and dry.
Psychiatric: Confused.

A review of PI # 1's medical record (from Hospital # 2) revealed documentation of Medicare Part B/Policy Number on the face sheet.

There was no face sheet in PI # 1's medical record provided by (Hospital # 1) to indicate PI # 1 did not have Medicare as documented in the ED record by (Hospital # 1) staff and reportedly provided to Hospital # 2 as documented in the ED record from Hospital # 1).

A review of the Medical record from Hospital # 2 (Free Standing Psychiatric Hospital) revealed:

Letter to Probate Judge from (Hospital # 1's ED Physician): Time not documented. (Copy received from Hospital # 2. Letter originated at Referring Facility, Hospital # 1, but the letter was not included in the certified copy of PI # 1's medical record provided by Hospital # 1 to the state surveyor).

PI # 1 presented to (Hospital # 1) ED (Emergency Department) on 1/13/16. Patient was admitted after being picked up by Police at Walmart wielding a butcher knife... was actively hallucinating and making delusional and paranoid statements. History of Schizophrenia. During PI # 1's time in the Emergency Department, PI # 1 has been exit seeking and pacing. PI # 1 is making decis

Based on review of Bylaws of the Medical Staff, Medical Staff Bylaws Appendix I, Rules and Regulations, policies and procedures, Utilization Management Program, medical records, AltaPointe Health Systems and EastPointe Hospital Consumer lists and interviews with facility staff, it was determined EastPointe Hospital (Hospital # 2), a free standing psychiatric hospital with capability and capacity failed to accept appropriate transfers of patients from Emergency Departments (ED) of medically stable patients who required continued psychiatric inpatient treatment based on a screening by the ED physician.

This affected 10 of 43 patients:
Patient Identifier (PI) # 17 on 2/22/16
PI #19 on 1/14/16;
PI # 1 on 1/14/16;
PI # 11 on 8/15/15;
PI # 12 on 2/21/16;
PI # 13 on 2/21/16;
PI #14 on 2/20/16;
PI # 15 on 1/20/16;
PI #16 on 1/30/16 and
PI # 18 on 2/11/16.
This deficient practice also has the potential to negatively affect all requests from hospital emergency departments of medically stable patients requiring continued psychiatric inpatient treatment at EastPointe Psychiatric Hospital.

Findings include:

1. PI # 17
PI # 17 presented to Hospital # 1's ED on 2/22/16 at 7:26 PM via ambulance with chief complaint of Psychiatric evaluation.


Review of the physician's documentation at 8:36 PM revealed the patient's history of present illness included: "... Patient information was obtained from patient... a 24 y.o. male who presents to the Emergency Department for psychiatric evaluation unknown onset with associated sx (symptoms) of audio and visual hallucinations. (PI # 17) states that he is hurting bad and needs his medication. He is on Seroquel but he has not been taking it... Notes that his nose is hurting like "someone is pressing on my face." Pt was seen at (Hospital # 6) ED 1-2 nights ago and was given mediations (medications) that have helped him... Hx (history) of Schizoaffective disorder... Review of systems times 10 was completed and is negative except noted... Unable to perform ROS (Review of System): mental acuity..."

PI # 17's Past Medical History diagnoses included Post traumatic stress disorder, Anxiety, Schizoaffective disorder, unspecified type and Hypertension.

Review of the Urine Drug screen lab results revealed the patient was positive for Amphetamine and Cannabis.

Review of the lab results for CBC revealed the patient's WBC was 10.5 (high), Hemoglobin 12.2 (low) and Monocytes Absolute 1.27 (Normal for this facility: 0-0.8). All other components were within normal limits.

(Leukocyte (white blood cell) that functions in the ingestion of bacteria and other foreign particles. Monocytes make up 5-10% of the total white blood cell count. labtestsonline.org)

Review of the lab results for CMP revealed the patient's Glucose was 106. All other components were within normal limits.

Differential Diagnoses: Potential conditions evaluated and ruled in or out by evaluation as above include, but are not limited to; 1. Psychosis, 2. Schizophrenia, 3. Anxiety, 4. Medication noncompliance.

Consultation or Discussion with another Provider:
9:18 PM. Discussed case with psych intake nurse. recc (recommend) admission. No beds. Will fax to care pointe once require by unnecessary labs are back, but psych intake reports that they "won't take him because he has no insurance, but I will send it anyway".

Reassessment: (PI # 17) reassessed at 9:18 PM. There has been good improvement in response to therapy and observation in the Emergency Department. Currently the clinical condition of the patient indicates that the patient would benefit from further stabilization, evaluation and/or treatment in the hospital. I have discussed the results of the testing and the reasons/goals for admission with the patient and any available family. Questions have been addressed and there is agreement with the plan.

Plan: medicate, eval for admit, fax to EastPointe.

Disposition: Floor

2/23/16 at 12:15 PM - patient is not suicidal. He has Seroquel at home. He will take that. He will be discharged and followup at Altapoint...

Review of the ED Notes dated 2/22/16 revealed the RN documented the following:

7:45 PM - "... (PI # 17) is not suicidal or homicidal. He states he needs medication to help him. He is speaking out loud to himself. He has a history of mental illness and medication non compliance... states that the vistaril is not helping him. Will follow up and report condition to ED physician..."

8:00 PM - " Pt to ED via EMS with complaint of needing psych evaluation and medications to stabilize his moods. Pt denies SI/HI (suicidal ideation/homicidal ideation) at this time..."

8:21 PM - "... Patient is talking to him self although he denies hearing voices or hallucinating. The patient is unable to answer questions correctly at this time. He is speaking with a deep southern drawl. This is different from the last time he was seen in this office. The patient is dressed in dirty clothes and in (is) unclean..."

8:23 PM - "... The patient states he is not suicidal or homicidal. He is responding to external stimuli..."

Review of the ED Orders dated 2/22/16 revealed the patient received Zyprexa 20 milligrams (mg) by mouth at 5:52 PM.

Review of the ED Notes dated 2/22/16 at 11:05 PM revealed the RN documented, "... (PI # 17) is medically cleared per ER MD..."

Review of the ED Notes dated 2/23/16 at 1:15 AM and 3:14 AM revealed the RN documented the patient was resting quietly, no distress noted and will continue to monitor.

Review of the ED Notes dated 2/23/16 at 5:30 AM revealed the RN documented having faxed the patient's chart to multiple facilities including, "... Chart faxed to Carepointe..."

Review of the ED Notes dated 2/23/16 revealed the RN documented the following:

8:48 AM - "... Pt resting quietly in bed. No c/o or distress. He is to be admitted to the Psych floor when bed available..."

9:10 AM - "... from (Hospital # 9) said she had no beds at this time..."

9:30 AM - "... (EI # 15, Crisis - Hospital Coordination Specialist) from Care Pointe called to say they were unable to accommodate..."

12:12 PM - "... (PI # 17) awake. Pt states he had a verbal altercation with dad last night and had an anxiety attack... want food, some pain medicine for his ankle and anxiety medication... Also requests to go home... denies suicidal and homicidal ideation... denies auditory and visual hallucinations... doesn't appear to be responding to internal stimuli at this time. Discussed with Dr (Named ED physician). Pt states he has meds at home. Was encouraged to take meds as prescribed and f/u (follow up) with Alta Pt (AltaPointe). Resources given for rehab. Pt verbalized understanding..."

12:22 PM - Education regarding medications, including indications and possible side effects, completed with patient/family verbalizing understanding..."

The patient was discharged on 2/23/16 at 12:29 PM with discharge instructions.

Review of records obtained from CarePointe and EastPointe Hospital:

Review of the Fax Transmittal Cover Sheet from Hospital # 1 revealed the documents, which included PI # 17's medical record information from Hospital # 1 were sent to CarePointe on 2/23/16 at 5:22 AM.

Review of the Care Pointe Call Intake documentation dated 2/23/16 at 9:05 AM revealed, EI # 15 documented, "... (Hospital # 1) seeking inpatient services. We are unable to accommodate, consumer (PI # 17) does not meet criteria at this time.

Review of the Care Pointe Pre-Intake Information dated 2/23/16 at 9:30 AM revealed EI # 15 documented, "... (Hospital # 1) referring consumer for IP (Inpatient) services... Presenting Problem and/or General Admission criteria (include precipitating factors or event(s)that led to/prompted crisis: (Hospital # 1) referring consumer for IP services. Consumer denies SI/HI as well as AH/VH (auditory hallucinations/ visual hallucinations). He will be found talking to himself and is disheveled. Consumer is asking for medications... Appointment Information... Notify Outgoing Comments: UTA (Unable to accommodate) Does not meet criteria..."

Review of the AltaPointe Health Systems, EastPointe Hospital Consumer list dated 2/22/16 revealed there were 42 consumers admitted to Hospital # 2, 19 of which were voluntary consumer admissions. This meant Hospital # 2 had a total of 24 hospital beds, 17 of which were designated for voluntary patients available to admit PI # 17.

2. PI # 19
PI # 19 presented to Hospital # 1's ED on 1/13/16 at 9:18 PM via ambulance with chief complaints of psychiatric evaluation.

Review of Hospital # 1's Emergency Department (ED) physician's documentation 1/14/16 at 5:56 AM revealed the patient's history of present illness included, "... Patient is a 26 y.o. male presenting with mental health disorder. The history is provided by the patient. Mental Health Problem: The primary symptoms include bizarre behavior and somatic symptoms. This is a chronic problem. The somatic symptoms do not include fatigue, headaches or abdominal pain. The onset of the illness is precipitated by a stressful event, alcohol abuse and drug abuse. The degree of incapacity that he is experiencing as a consequence of his illness is moderate. Sequelae if the illness include the inability to work, an inability to care for self, harmed interpersonal relations and homelessness. Additional symptoms of the illness include agitation and poor judgment. Additional symptoms of the illness do not include no appetite change, no fatigue, no headaches or no abdominal pain. He admits to suicidal ideas. He does have a plan to commit suicide. He does not contemplate harming himself. He has not already injured self. He does not contemplate injuring another person. Risk factors that are present for mental illness include substance abuse and a history of mental illness...

Review of Systems including Constitutional, HENT, Eyes, Respiratory, Cardiovascular, Gastrointestinal, Endocrine, Genitourinary, Musculoskeletal, Skin, Neurological and Hematological were all documented as negative. Psychiatric/Behavioral was documented positive for suicidal ideas, behavioral problems and agitation.

Review of the Urine Drug screen lab results revealed the patient was positive for cannabis and alcohol level of 69 (normal for this facility < 10). All other components were within normal limits.

Review of PI # 19's Urinalysis lab results revealed the patient had a trace of Ketones (Normal for this facility negative). All other components were within normal limits.

Review of the ED Notes dated 1/13/16 revealed the RN documented the following:

9:30 PM - Patient arrive by ambulance via stretcher... states he has been on his psych medicine for over a month and has been having thoughts of wanting to hurt himself... has no specific plans... denies wanting to hurt anybody else... states he is homeless and has had increased stress. Patient will not give me any details and is very vague..."

10:00 PM - "Pt presents to ER via EMS for psych evaluation. Pt states he is feeling suicidal and wants to jump in the Mississippi River. "Don't nobody care. I'm just tired of this (expletive)."... states he is homeless but does not want to live with his parents because, "He be expecting me to do stuff without him telling me... states he has not been taking his medications. When asked about his non-compliance, pt states, "They want me to pay some money I ain't got" This contradicts pt's past statements regarding his medication regimen when he told another psych intake nurse that he "just didn't feel like it". (PI # 19) requests to be sent upstairs. When informed this, pt states "well can yall send me to Eastpointe?" Possible seeking secondary gain from admission? Pt denies HI and AH/VH. No psychosis noted. Will discuss with ER MD..."

Review of the ED Notes dated 1/14/16 revealed the RN documented the following:

12:45 AM and 2:53 AM - ".... Pt resting quietly. No distress noted. Will continue to monitor..."

3:30 AM - " ER MD to see pt. Pt medically cleared..."

4:56 AM - Pt resting quietly. No distress noted. Will continue to monitor..."

5:13 AM - "... Chart faxed to Carepointe and (another hospital) for Psych Med. Spoke with Eastpointe and was told there are no beds available but to try again at around 8 AM..." (There was no documentation of who at Eastpointe told the RN there were no beds.)

On 1/14/16 at 7:31 AM, the RN documented having called two other facilities and was told there were no beds available.

Review of the ED Notes dated 1/14/16 revealed the RN documented the following:

7:00 AM - "... (PI # 19) loud and intrusive with other patient in Intake. (Psychiatric unit within the ED) Patient states "You might as well let me go so I can get even more depressed and kill myself." Patient agrees to be transferred to another psychiatric hospital. No beds available at (Hospital # 1)..."

On 1/14/16 at 7:20 AM the nurse documented having called 3 additional facilities (located in an adjacent state). Two of the facilities reported the nurses were in report and would have to call back, the third stated that intake would have to call back.

Review of the ED Notes dated 1/14/16 revealed the RN documented the following:

8:00 AM - "... Received patient from psych intake. No acute distress noted at this time. Sitter at bedside. Patient states, "I want to jump off the Mississippi bridge"..."

8:25 AM (Nursing Assistant) - "... Spoke with (EI # 16, Aftercare and Referral Specialist) at Care Pointe and was told they was still reviewing the chart... would call us back if they need any additional information..."

9:00 AM - "... Received a call from Access to Care. Spoke with (EI # 16) they are requesting updated chart. Chart re faxed to Access to Care. Awaiting return call..."

9:58 AM (Nursing Assistant) - "... Fax chart to Access to care at 0420 (4:20 AM), Was called at 0915 (9:15 AM) to fax updated chart. Updated chart was faxed at 0930 (9:30 AM)..."

10:32 AM (RN) - "... Pt stated he was homicidal. Ready to go home. Dr. (Named ED physician) notified..."

10:41 AM - "... (PI # 19) requesting to leave "I don't want to be sent no where. I am ready to go!" Patient denies any suicidal or homicidal ideations at this time. Patient was instructed to go to Alta Pointe as a walk in today. "I ain't got no way to get there. Bus pass offered to the patient. Patient replied "I need more than a bus pass, I give plasma on Thursday's". Patient is not psychotic and does not appear to be delusional. Mood is demanding and entitled. Discussed with MD..."

10:51 AM - " The patient left AMA (against medical advise) after discussing the risks, benefits, and alternatives with Dr. (Named ED physician). The patient signed the AMA form... patient left prior to completion of the Medical Screening Exam. Dr (Named ED physician) aware..."

PI # 19 departed from Hospital # 1's ED against medical advice (AMA) on 1/14/16 at 10:53 AM in "good" condition.

Review of records obtained from CarePointe and EastPointe Hospital:

Review of the AltaPointe Health Systems, EastPointe Hospital Consumer list dated 1/13/16 revealed there were 47 consumers admitted to Hospital # 2, 21 of which were voluntary consumer admissions. This meant Hospital # 2 had a total of 19 hospital beds, 15 of which were designated for voluntary patients available to admit PI # 19.

Review of the AltaPointe Health Systems, EastPointe Hospital Consumer list dated 1/14/16 revealed there were 48 consumers admitted to Hospital # 2, 23 of which were voluntary consumer admissions. This meant Hospital # 2 had a total of 18 hospital beds, 13 of which were designated for voluntary patients available to admit PI # 19.

Review of the Fax Transmittal Cover Sheet from Hospital # 1 revealed the documents, which included PI # 19's medical record information from Hospital # 1 were sent to AltaPointe on 1/14/16 at 4:50 AM and again on 1/14/16 at 9:26 AM.

Review of the Call Intake information dated 1/14/16 at 8:45 AM revealed EI # 1, Hospital Admission & Referral Coordinator CarePointe documented, "... (Hospital # 1) is referring consumer for inpatient care... "

Review of the Pre-Intake information dated 1/14/16 at 10:04 AM revealed EI # 1 documented, "... (Hospital # 1) is referring consumer (PI # 19) for inpatient care... Hospital Screening... Did a NON-AHS professional (doctor, therapist etc) recommend EP... Hospital services? No... Referral Source: Hospital... Symptoms / Risk Factors Reported: Current/hx (history) of med non-compliance, Current/hx of treatment non-compliance, Depressive symptoms, Hopelessness, Mental illness, Poor coping skills, Suicidal Ideation/ Current, Suicide ideation with plan, Use of Alcohol or drugs. If PLAN or ideations, please list How recent or if current, means, when, who, etc: Consumer is experiencing SI with a plan to jump into the Mississippi River... Presenting problem and/or general admission criteria (include precipitating factors or event(s) that led to/prompted crisis: (Hospital # 1) is referring consumer for inpatient care. Consumer reports SI with a plan to jump into the Mississippi River. He has not been compliant with taking his medications for the past month. He is homeless and states that he does not want to live with his parents... UDS (Urine drug screen) was positive for marijuana (cannabis)... Appointment Information... (10:20 AM) Notify Outgoing Comments: (Hospital # 1) to EP (EastPointe)/ Selfpay (bridge team)/ pending review... "

Review of an email sent from EI # 1 to EI # 3, Clinical Coordinator Hospital # 2, EI # 13, Assistant Director Hospital # 2 and cc (carbon copy) to EI # 2, Assistant Director of CarePointe... dated 1/14/16 at 9:56 AM revealed, "Subject: For review/ (PI # 19)... (PI # 19), no insurance but his chart shows that he is receiving bridge team services, SI with a plan to jump into the Mississippi river, homeless, non-compliant with psych meds..."

Review of a second email sent from EI # 1 to the same recipients on 1/14/16 at 11:16 AM, revealed, "... Please disregard this one - Consumer left (Hospital # 1) AMA..."

CarePointe staff received a request for transfer for PI # 19 on 1/14/16 at 8:45 AM. The next documentation related to transfer of PI # 19 was completed on 1/14/16 at 10:04 AM, which was 1 hour and 19 minutes after the original request was received.

There was no documentation the request for transfer was reviewed by the East Pointe psychiatrist.

An interview was conducted on 3/17/16 at 10:39 AM with EI # 1, Hospital Admission & Referral Coordinator CarePointe. The surveyor presented PI # 19's referral information. The surveyor asked if she recalled the patient. She stated she remembered the name. The surveyor asked if the patient met criteria for admission. She stated that she would assume that he does because of suicidal ideation with a plan. She stated that she did not know if it got to that point because Hospital # 1 called back to let us know the patient left AMA (Against Medical Advice). She stated she did not know if the referral information was sent to the psychiatrist or not because once the patient left AMA, it "kind of stops there."

3. PI # 1
Medical Record Review: Hospital # 1:

ED (Emergency Department) Notes:

Arrival Date/Time: 1/13/16 at 7:59 PM via ambulance.
Triage Time: 8:07 PM
Acuity: Urgent.
Chief Complaint: Psychiatric Evaluation

1/13/16 at 8:09 PM: First ED Note by Registered Nurse (RN): Patient ( PI # 1) arrived via stretcher from Walmart parking lot. EMS (Emergency Medical Services) states PI # 1 was walking across the parking lot holding a butcher knife. Per EMS the patient's Mom reports PI # 1 has been off medication and has a psychiatric diagnosis, but she does not know medications or diagnosis. Patient awake, alert, confused to place and time and unable to answer any questions correctly. Patient blurting out random words.

1/13/16 at 9:05 PM: Haldol 5 milligrams (mg.), Benadryl 50 mg. and Ativan 2 mg. injections given to PI # 1.

1/13/16 at 9:35 PM: "Psych consult" by RN: Patient arrives to ER (Emergency Room) per EMS after being found wandering around a parking lot with a knife in hand. Speaking in word salad: "The missiles are there and my head is above them." Appears extremely paranoid, continually scanning the room. Difficulty following simple verbal commands. Responds to internal stimuli. ...UDS (urine drug screen) negative...Case discussed with MD (Medical Doctor).

1/14/16 at 6:19 AM: Spoke with patient's mother. Previous diagnosis of schizophrenia... According to the mother PI # 1 said, "They gone to try to get us but they ain't gone get us. Before I knew it, ... (PI # 1) was outside the parking lot with a butcher knife." Per patient's mother... (PI # 1) has been non-compliant with medications and refuses to seek treatment.

1/14/16 at 7:00 AM: Nursing documentation revealed multiple attempts to find inpatient treatment for PI # 1, but no psych beds were available.

1/14/16 at 8:21 AM: PI # 1 has flight of ideas. Thoughts are loose and disorganized, and is responding to internal stimuli. "Germans and credit cards." Rambles about military bases. Patient cooperative and agrees to transfer to a psychiatric hospital.

Medically cleared by (Hospital # 1's ED Physician). "No beds available" at (Hospital # 1/Referring Hospital).

1/14/16 at 8:50 AM: Patient (PI # 1) pacing rapidly in room. "I need to go to a military base." ... Appears very psychotic. Agrees to take medication.

1/14/16 at 8:55 AM: Haldol 5 mg., Benadryl 50 mg. and Ativan 2 mg. injections given to PI # 1.

1/14/16 at 9:00 AM: Chart faxed to (Call/Referral Center for Hospital # 2).

Review of the Referral for PI # 1 for inpatient psychiatric treatment by (Hospital # 1) Emergency Department Staff to Hospital (Hospital # 2) intake staff:

A review of the AltaPointe Systems, Inc. Hospital Referral Form revealed Patient Identifier (PI) # 1 was referred to EastPointe Psychiatric Hospital (Hospital # 2) for inpatient treatment on 1/14/16 by (Hospital # 1).

1/14/16 at 9:04 AM:

"1. Identification Section:
Hospital use only.. No documentation of legal status (voluntary versus involuntary).
Referral Source: Hospital...
Hospital: (Hospital # 1 - referring hospital).

* No insurance information documented by (Hospital # 1)

2. Symptoms/ Risk Factors: No documentation...

3. Presenting problems and/or General Admission Criteria: Hospital referral received from (Hospital # 1). Hospital # 2) is UTA (unable to accommodate) "SP (Self-pay)/non-intensive."

Verified definition of "SP/non-intensive" during a telephone interview with Employee Identifier (EI) # 12, Director Performance Improvement, at 2:30 PM on 3/23/16 to mean, "Self pay for non-intensive services. The patient (PI # 1) did not require inpatient." The patient could have been treated as an outpatient as determined by the therapist at AltaPointe (Referral/Intake Center for EastPointe Hospital).

6. Prior Psychiatric Hospitalization:
AltaPointe psychiatric history (include previous treatment): None

Name of Physician Consulted: No documentation


Medical Record Review: Hospital # 1:

ED (Emergency Department) Notes:

1/14/16 at 9:15 AM: Received a call from EI # 1, Hospital Admission and Referral Coordinator, Intake Center for Hospital # 2. They are unable to accommodate patient at this time. Per EI #1, "It is not due to availability of beds or clinic appropriateness. It is a company policy... " Clarified with EI # 1 that they (Hospital # 2) do have beds and clinical documentation was appropriate.

1/14/16 at 12:38 PM: Call placed to (Hospital # 2's Hospital's Intake/Referral Center) by (Hospital # 1's) ED staff. It was noticed patient has Medicare. Previous insurance face sheet had no insurance documented. Hospital # 2 asked us (Hospital # 1) to resend face sheet.

1/14/16 at 2:30 PM: Call placed to Hospital # 2's intake center from Hospital # 1. Spoke with EI # 16, Aftercare and Referral Specialist at Hospital # 2, who said, "The doctor has not reviewed the chart." Patient's (PI # 1) thoughts remain loose and disorganized...

1/14/16 at 2:35 PM: ... Chart has not changed since this AM... Only change: "We (Hospital # 1) found out the patient does have insurance."

1/14/16 at 3:00 PM: Received a call from EI # I, "We need to know if the patient is voluntary." Explained PI # 1 is psychotic and is thought blocking. Unable to determine if patient can give consent.

1/14/16 at 3:51 PM: PI # 1 pacing in room (remains in ED at Hospital # 1). Asked patient if he is hearing voices. PI # 1 states, "Not to much. Jamaican. Have you ever been in a helicopter?"

1/14/16 at 4:04 PM: Received a call from EI #1, Admission Referral Coordinator - Hospital # 2's Intake Center, who states, "They (Hospital # 2)are willing to accept the patient (PI #1) on a voluntary basis and if he becomes involuntary at EastPointe then they will be glad to file a petition to hold him..."

1/14/16 at 4:27 PM: Sheriff here from probate court. Patient (PI # 1)discharged to sheriff.

A review of the AltaPointe Systems, Inc. Hospital Referral Form dated 1/14/16 at 5:04 PM revealed:

1. Identification Section:
Hospital use only...Voluntary
Referral source: Hospital
Hospital: (Hospital # 1/Referring Hospital)...

Insurance Information:

Does the consumer (patient) have insurance? Yes

Insurance Provide: Medicare

Does the consumer have secondary insurance? Yes

Insurance Provider: Medicaid...

... 2. Symptoms/Risk Factors:
"Agitation, aggression, assault. Current history of med (medication) non-compliance. Delusions or hallucinations, Mental illness symptoms worsening,... Neglecting daily responsibilities, Poor coping skills..." (meaning unknown)

If hallucinating, delusional or COMMAND hallucinations, please specify: Consumer (PI # 1) arrived to the ED by ambulance on 1/13/16. Consumer's (Patient's) mother called 911 after consumer was found walking around the Walmart parking lot holding a butcher knife stating, "The missiles are there and my head is above them." PI # 1 is extremely paranoid and disorganized. His mother reports that PI # 1 has a past diagnosis of paranoid schizophrenia, but has been noncompliant with meds (medications) and treatment since moving here from Ohio seven months ago. PI # 1 is agreeable to be transferred to a psychiatric hospital.


Review of Hospital # 1's ED Physician Documentation:

1/14/16 at 5:44 PM: This case is a certified medical emergency.

HPI (History of Present Illness): Limited by patient condition. Patient (PI # 1) arrives to ER after being found wandering around a parking lot with a knife in his hands. Speaking in word salad. Appears extremely paranoid. Difficulty following simple verbal commands. Responds to internal stimuli...

Physical Examination: BP (Blood pressure): 138/80, Pulse: 99, Temp: 98.6, Resp (respirations): 20

PI # 1 appears well developed and well nourished.
Head: Normocephalic and atraumatic.
ENT (Ears, Nose, Throat): Normal
Eyes/Neck: PERRL (Pupils equal, round, reactive to light). Normal ROM (Range of Motion).
Cardiovascular: Normal rate and rhythm.
Pulmonary: Breath sounds normal.
Abdominal: Soft. Bowel sounds normal.
MSK (Musculoskeletal): Normal ROM.
Neuro (Neurological): Normal reflexes. No cranial nerve deficit.
Skin: Warm and dry.
Psychiatric: Confused.

A review of PI # 1's medical record (from Hospital # 2) revealed documentation of Medicare Part B/Policy Number on the face sheet.

There was no face sheet in PI # 1's medical record provided by (Hospital # 1) to indicate PI # 1 did not have Medicare as documented in the ED record by (Hospital # 1) staff and reportedly provided to Hospital # 2 as documented in the ED record from Hospital # 1).

A review of the Medical record from Hospital # 2 (Free Standing Psychiatric Hospital) revealed:

Letter to Probate Judge from (Hospital # 1's ED Physician): Time not documented. (Copy received from Hospital # 2. Letter originated at Referring Facility, Hospital # 1, but the letter was not included in the certified copy of PI # 1's medical record provided by Hospital # 1 to the state surveyor).

PI # 1 presented to (Hospital # 1) ED (Emergency Department) on 1/13/16. Patient was admitted after being picked up by Police at Walmart wielding a butcher knife... was actively hallucinating and making delusional and paranoid statements. History of Schizophrenia. During PI # 1's time in the Emergency Department, PI # 1 has been exit seeking and pacing. PI # 1 is making decisions based on psychotic thinking and has little to no insight into current limitations.

I (Hospital # 1's ED Physician) have concerns about the patient's safety awareness and feel patient could pose a threat to self or others if returned to the community. We request you consider PI # 1 for further evaluation and a candidate for involuntary treatment.

Emergency Detention Order Signed by Probate Judge on 1/14/16: (Copy received from Hospital # 2). Although this form originated at Hospital # 1, it was not included in the certified copy of the medical record provided by Hospital # 1 to the surveyor).

1. The Respondent (PI # 1) shall be detained and confined on an emergency basis at EastPointe Hospital...

Facsimile Transmittal Cover Sheet from (Hospital # 1) to
(Hospital # 2) :

Date: 1/14/16 (included in medical record from Hospital # 2):
Handwritten time: 8:40 AM
Facsimile Time: 12:28

(Rationale for report inclusion: This is the only documentation of time clinical information/request for inpatient hospitalization was sent by Hospital # 1/Referring Facility.

Pre-Intake Information Psychiatric Call Center for Hospital # 2:

1). Date: 1/14/16
Start Time: 12:57 PM
Reason: (Hospital # 1) referring consumer for inpatient care.
Insurance: Yes
Provider: Medicare
Comment: Patient is Voluntary. Pending review.

2). Call Intake:
Call Date: 1/14/16
Call Time: 4:58 PM
Comments: Consumer (PI #1) has active Medicare with psych days. Forwarded paperwork to Hospital # 2 for doctor to review. Notified (by Hospital # 2's clinical staff) that an emergency petition was filed by Hospital # 1.

Spoke to (first name of Registered Nurse in ED at (Hospital # 1) who felt "consumer" (PI # 1) unable to consent to inpatient treatment due to psychotic state. (Hospital # 1) will move forward with involuntary process.

Nursing Admission Assessment Hospital # 2:
Date: 1/14/16 Time: 5:43 PM

Reason for admission: Consumer (PI #1) unable to answer; only made incoherent statements.

Psychiatric Evaluation Hospital # 2:

Date: 1/15/16
Chief Complaint: "I investigated top criminals on the computer. The military telling him who to be." Actively delusional and paranoid. Disorganized thought processes, responding to internal stimuli.
Diagnoses: Schizophrenia, Medication Noncompliance, Rule out Borderline Intellectual Functioning.

Interviews:

During an interview on 3/10/16 at 12:30 PM with EI # 1, the Hospital Admission and Referral Coordinator, Hospital # 2's Intake Center CarePointe (CP) was asked to define the meaning of what she allegedly said and was documented in a note (dated 1/14/16 at 9:20 AM in PI # 1's ED record from Hospital # 1 (Referring hospital), "Received a call from (EI # 1's name) at Access to care. They are unable to accommodate the patient (PI # 1) at this time. Per EI # 1, "It is not due to availability of beds or clinic appropriateness. It is a company policy ... " She stated that what she said was misleading. There is no company policy. he statement "unable to accommodate" is a way to explain denial of request for inpatient treatment. The surveyor asked what changed regarding PI # 1 other than the notice the patient had Medicare. She stated the first request for inpatient psychiatric treatment was not sent to (Hospital # 2's) psychiatrist. The surveyor asked EI # 1 to explain and she stated, "Did not know if PI # 1 met MCG criteria, unaware if patient involved in AltaPointe intensive service, unknown if patient was voluntary, patient had no insurance ..." The surveyor asked if the patient's information was sent to the psychiatrist once it was known the patient had insurance and the response was "yes." The surveyor asked if PI # 1's clinical status changed and EI # 1 stated, "No."

4. PI # 12
A review of PI #12's medical record from (Hospital # 1) revealed the patient presented to the ER (Emergency Room) via EMS (Emergency Medical Services) on on 2/21/16 due to "... pain because someone is beating him/her in the back." History of Schizophrenia. Patient is responding, sometimes aggressively, to internal stimuli. PI # 12 states, "I am the princess of every country and my father is the