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LAKELAND REGIONAL MEDICAL CENTER 1324 LAKELAND HILLS BLVD LAKELAND, FL 33805 July 25, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on facility document review, staff interview and review of facility policy and procedures it was determined the facility was not in compliance with 42 CFR 489.24.

The facility failed to accept from a referring hospital an appropriate transfer of an individual who required psychiatric services, in which the facility had capability and capacity for one (#2) of eleven transfers reviewed of twenty patients
VIOLATION: RECIPIENT HOSPITAL RESPONSIBILITIES Tag No: A2411
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, ambulance run sheets, transfer logs, transfer event summary report, facility on-call physician schedules, policies and procedures and staff interviews, the facility refused to accept from a referring hospital (Hospital 1) within the boundaries of the United States an appropriate transfer of an individual (#2) who required such specialized (psychiatric) capabilities or facilities and when the receiving hospital (hospital #2-Lakeland Regional Medical Center ) had the capacity to treat one (#2) of eleven (11) transfers of twenty sampled patients.

Findings included:

Patient #2's ambulance run sheet dated 7/13/2017 was reviewed. The ambulance run sheet, the section titled "Narrative" revealed in part, "Dispatched to possible attempted suicide ...scene secured and arrived at 1008. Pt. (patient) found sitting on couch. In no distress ...on scene advising pt. had made complaint that he wanted to kill himself, after his mother caught him/her huffing compressed air from an air duster can. Pt. admitted to huffing approx. (approximately) half can for fun. He/she stated that he/she was not trying to kill self, and that he/she has [DIAGNOSES REDACTED] and cannot drink alcohol. He/she told his/her mother that he/she felt like he/she would be better off dying, so she called 911. Officers advised that pt. wears a heart monitor 24/7 ...needs to be medically cleared ...He/she walked to stretcher ...care and report to nurse (Hospital B).

The Medical record from at Hospital #1 revealed that patient #2 was registered in the hospital's emergency room on [DATE] at 10:34 a.m. Review revealed the patient was seen by the emergency department physician and medically cleared for psychiatric placement. The psychiatrist was consulted on 7/13/2017. Documentation by the psychiatrist revealed that patient #2 presented to the emergency department under police Baker Act after making passive suicidal ideation threats at home. The patient has a history of depression and anxiety. Documentation also revealed the patient's mother was interviewed and reported concerns that Patient#2 had been increasingly depressed over the past few days. The patient has severe [DIAGNOSES REDACTED] which is secondary to alcohol use and is currently wearing a life vest and the patient reported his/her mood has been "very depressed" making e statements like "I am not going to live much longer" and before the patient began huffing the compressed air today the patient added "I might as well just do this." The mother also reported that the patient had been repeatedly taking the life vest off and stating "I don't care" and the patient's mother is concerned about the patient's safety at home. An addendum note by the psychiatrist dated 7/13/2017 at 7:09 pm revealed in part, "psychiatry, ...consult recommends continuing to try to send to baker act facility ...will not rescind the backer act and will still need to be sent to a backer facility." Further review of the record revealed that on 7/15/2017 a physician documented in part, "Patient has been in the emergency room for greater that 30 hours while case management is attempting to find psychiatric facility that will accept patient for his condition. He been denied at multiple facilities due to ... life vest ...currently on 1:1 observation."

Review of the facility's (Hospital #2) transfer log revealed a request for patient #2 to be transferred to the receiving facility for psychiatric services on 7/13/2017.

Review of the transfer event summary from Hospital #2 revealed the psychiatric charge nurse received the request on 7/13/2017 at 9:30 p.m. Documentation stated the patient was being held under the Baker Act (BA) and wore a LifeVest. The LifeVest was a wearable defibrillator worn by patients at risk for sudden cardiac arrest. The event summary stated the patient was not accepted. The reason stated the patient was not accepted due to the inability to safely care for the patient due to the patient's need to wear a LifeVest at all times for the heart condition.

Review of the facility policy "Patient Transfers", stated the facility shall accept emergency patient transfers when the following conditions are met: (1) a qualified member of the attending medical staff is available to provide care for the patient; (2) there are appropriate beds and staff available within the facility at the time the transfer is requested; (3) the transferring facility has indicated that it cannot provide the care needed by the patient; (4) the facility has the specialized capabilities or facilities to treat the patient and (5) the transferring physician certifies an emergency medical condition exists.

The policy stated all requests for transfer from other healthcare facilities are documented in the transfer log by the Patient Placement Representative or on the arrival screen in the facility system. Requests for emergency transfer are also documented in the Risk Management online occurrence form by the Administrative Manager.

The policy stated in the event transfer arrangements cannot be completed, the Administrative Manager notifies the Administrator On Call. Key information to be included in the online occurrence form is the date and time of each conversation, name and position of each participant e.g., receiving physician, referring physician, ED nurse, transfer deemed medically emergent or non-emergent and if transfer is not accepted, the reason(s) for declining the transfer and the name of the Administrative Manager or Administrator On Call who made the decision to decline the transfer

Review of the receiving facility license revealed the facility offered cardiology services, cardiovascular surgery and was a Level 2 Adult Cardiovascular service provider.

Review of the physician on-call list for psychiatry for 7/13/2017 revealed an on-call physician was available to provide care for the patient #2.

Review of the psychiatric unit census revealed the census on 7/13/2017 at 9:00 p.m. was 22. The unit's capacity was 30. Review of the psychiatric unit census revealed appropriate staff was available as evidenced by other psychiatric patient admission on the same day and shift. Review of the event summary revealed the transferring facility did not provide psychiatric services.

Interview with the Director of Mental Health Services on 7/24/2017 at 2:30 p.m. indicated the facility process for request of ED (Emergency Department) to ED transfers into the facility for psychiatric services included routing the request directly to the psychiatric unit Charge Nurse. The nurse would request BA (Baker Act) paperwork to check for completeness, ask if the patient was medically cleared, look at the unit's capacity and call the on-call physician. The Director of Mental Health Services confirmed the Charge Nurse, that received the call on 7/13/2017, did not call the on-call psychiatrist or notify the Administrator On Call of her decision to not accept the transfer of the patient. The facility failed to ensure that staff adhered to decision protocols within the hospital arrangement of incoming transfer of patient #2 on 7/13/2017.

An interview was conducted with the Nursing Director of Cardiac Services and Quality Manager/Patient Safety Officer on 7/24/2017 at 1:25 p.m. The Nursing Director of Cardiac Services stated patients with a Life Vest are educated about them. The Life Vest was a prophylactic treatment used for the patient's underlying cardiac condition. He stated he saw no reason why the patient could not be treated in the psychiatric unit with a Life Vest in place. He stated the psychiatric staff could call the facility's rapid response team or a cardiac nurse should any issues arise with the patient. He stated there was no special monitoring that was required by the nurse in order to care for the patient with a LifeVest.

Interview with the Associate Vice President of Regulatory/Medical Affairs on 7/24/2017 at 2:35 p.m. stated if the patient presented to our ED the patient would have been admitted to cardiac services and a sitter provided.

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to accept from a referring hospital an appropriate transfer of Patient #2, who required psychiatric services, in which the facility had capability and capacity on 7/13/2017.