The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

PRESENCE COVENANT MEDICAL CENTER 1400 WEST PARK AVENUE URBANA, IL 61801 Jan. 25, 2012
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
A. Based on a clinical record, a review of Hospital policies, a review of psychiatric unit staffing grids, a review of psychiatric unit referral intake forms, a review of psychiatric unit census, and staff interview, it was determined the Hospital failed to ensure the patient and or patient representative was informed of the risks and benefits of the transfer and physician failed to complete a detailed physician certification that indicated the risks and benefits of the transfer. Please see the deficiency at A2409. The Hospital failed to ensure all patients requiring specialized psychiatric care, which the Hospital provides, were accepted for transfer to its Hospital when the capacity and staffing allowed acceptance. Please see the deficiency at A .
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on clinical record review and staff interview, it was determined in 2 (Pt.#6, #14) of 20 clinical records reviewed, in which the patient was transferred to an outlying Hospital, the Hospital failed to ensure the patient and/or the patient's representative was informed of the risks and benefits of the transfer and the Hospital failed to complete a detailed physician certification that indicated the risks and benefits of the transfer.

Findings include:

1. Pt. #6 presented to the ED (Emergency Department) on 01/01/12 at 7:00 am with a history of psychosis and bipolar disease. A psychiatric evaluation was conducted by the mental health professional at 8:35 am. Documentation on the crisis screening form indicated that due to Pt. #6's severity of psychosis, her past refusal to take medication and the risk Pt. #6 posed to herself and others, it was recommended that Pt. #6 be transferred to another Facility. Documentation further indicated that Pt. #6 had consulted with and agreed to be involuntarily admitted to another psychiatric facility. There was no petition for involuntary admission in Pt. #6's record, no authorization of transfer and no physician certification that included the risks or benefits of the transfer.

2. Pt. #6's ED record from the receiving hospital was reviewed on 1/27/12, the initial comprehensive assessment completed 1/1/12 indicated Pt. #6 was experiencing increased psychotic behaviors, had not been compliant with medications, and Pt. #6's physician recommended involuntary admission due to pt. #6's instability, increased aggression and active psychotic behaviors. Pt. # 6 was discharged on [DATE].

3. Pt. #14 (MDS) dated [DATE] with the diagnosis of depression, psychosis and suicidal ideation. ED consultant with Pt. #14's psychiatrist recommended admission to receiving hospital due to Pt. #14's chronic non-compliance, multiple past admissions and recent discharge of 1/9/12 from the hospital and that Pt. #14 needs longer term care. Pt. #14 was discharged by ambulance at 10:21 PM to receiving hospital. There was no documentation to indicate a physician certification had been completed prior to patient transfer that included the risks and benefits of the transfer.

4. Pt. #14's ED admission record of 1/13/12 from the receiving hospital was reviewed on 1/27/12, the Comprehensive Psychiatric Evaluation completed 1/13/12 indicated a diagnosis of Schizoaffective Disorder, Bipolar Type. Pt. # 14 is still an inpatient at the hospital as of 1/27/12.

5. The above findings were confirmed with the Director of Risk Management on 01/25/12.
VIOLATION: RECIPIENT HOSPITAL RESPONSIBILITIES Tag No: A2411
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on a review of Hospital policies, a review of Hospital staffing policy and grids, a review of Hospital intake forms, and staff interview, it was determined in 7 of 17 (Pt's #1, #2, #3, #6, #7, #9, #10) referral forms reviewed, in which the Hospital denied acceptance of a patient, the Hospital failed to ensure all patients requiring specialized psychiatric care, of which the Hospital provides, were accepted for transfer to its Hospital when the capacity and staffing allowed acceptance.

Findings include:

1. The Hospital policy titled " Scope of Care " (Revision date: 12/16/11) was reviewed on 1/24/12. It indicated. "Procedure: 4. Behavioral Health Unit accepts patients [AGE] and older based on existing unit acuity."

2. The Hospital policy titled "Patient Flow Process" (New Policy 2/28/11) was reviewed on 1/24/12. It indicated "Procedure: II. E. Census and bed availability will be defined by color codes- Green, Yellow, Orange, and Red ... VII. Behavioral Health Unit: A. Patients will be admitted after accepted by psychiatrist ... "

3. The "Patient Focused Care: Flex Staffing Plan Based on Unit Acuity: Psychiatric/ Behavioral Services " was reviewed on 1/24/12. It indicated that the number of Registered Nurses and technicians per shift was determined by the patient census.

4. The unit is licensed for 32 beds but utilizes 24 beds. The staffing grid for 1/7/12 thru 1/9/12 was reviewed on 1/24/12. It indicated the census ranged from 8 to 17, which indicates that beds were available.

5. A staff interview was conducted on 1/24/12 at 11:40 AM, per telephone, with the Psychiatrist on-call for 1/7/12 (E-1). The Director of Risk Management was present during the interview. E-1 verbalized uncertainty as to whether the receiving hospital had a process in place to address the evaluation of acuity levels of its' patients. "It depends on what is going on on the unit and whether the patient meets criteria for admission." It was further verbalized that Pt's with the primary diagnosis related to substance abuse would not be accepted; however, information on substance abuse treatment centers would be given to the requesting hospital. Pt's with Developmental Disabilities (DD) patients "are admitted if they are able to provide the appropriate level of care needed; however, if the care is beyond what they usually deal with they may refer to the other tertiary facilities first."

6. A staff interview was conducted on 1/24/12 at 1:00 PM per telephone with the intake nurse who took referrals on 1/7/12 (E-2). The Director of Risk Management was present during the interview. It was verbalized that the intake nurse had worked on the psychiatric unit for 30 years. When asked how acuity issues are evaluated, it was verbalized that "It depends on what is going on with the patients." When asked what the process for the evaluation of acuity, it was verbalized that "there isn't an official policy or process. It doesn't go by numbers. It goes more by our gut feeling and how the patients are behaving. The doctor makes the final determination. That is not something in my scope to do." It was further verbalized that the unit "does care for substance abuse patients; but, it is not the primary diagnosis for the patient because we aren't a substance abuse treatment center. We give a list of resource centers available when places call for beds and the primary issue is felt to be a substance abuse situation instead of a psychiatric situation." When asked about the care of DD patients, it was verbalized that they do also take care of DD patients "but the severity of their problem determines this. We have a list of DD facilities that better serve them that we refer to if we feel it is more appropriate care." When asked about the acceptance of homicidal patients, it was verbalized that "again, it depends on the situation but we have."

7. A list of psychiatric referral forms for the dates 1/7/12 thru 1/9/12 was reviewed on 1/24/12. It indicated 17 referrals were received between 1/7/12 and 1/9/12. Four (4) of seven (7) referrals received on 1/7/12 were declined. Three (3) of 10 referrals received on 1/8/12 were declined. Please see below.

8. The referral form of Pt #1 was reviewed on 1/25/12. It indicated Pt #1 was referred to the hospital from another hospital Emergency Department (ED) on 1/7/12 at 7:45 PM with "Initially came in for HIVES - If not admitted will kill himself - Hates Job-Boss-Living situation...wants to drink himself to death..." At 7:55 PM "Reason for denial: Pt acuity."

9. During a staff interview conducted with the Director of Risk Management on 1/24/12 at 10:00 AM, it was verbalized that the referral call regarding Pt #1 was initially refused admission per the on-call Psychiatrist due to "acuity." The transferring hospital later returned a call to the hospital complaining that refusing Pt #1 was an EMTALA issue. The hospital then contacted the Director of Risk Management between 9:00 PM and 10:00 PM to inquire as to whether to accept the transfer and were then instructed that the hospital was to accept the transfer since the hospital had an open bed. Pt #1 was then accepted and admitted on [DATE] at 1:20 AM.

10. The referral form of Pt #2 was reviewed on 1/25/12. It indicated Pt #2 was referred to the hospital from another hospital ED on 1/7/12 with "Psych consult recommended treatment... Pt #2 is distraught- suicidal- plan to drive off bridge... History angry and violent feelings... Physically and verbally abusive- narcissistic, estranged from children... Afraid will hurt self or wife... Earlier stated not suicidal but then thought maybe Pt #2 was... Reason for denial: Acuity, plus questionable if patient meets criteria for involuntary and not enough info."

11. The referral form of Pt #3 was reviewed on 1/25/12. It indicated Pt #3 was referred to the hospital from another hospital ED on 1/7/12 with "long history Depression and attempts... voices to hurt self/others... Reason for denial: Acuity."

12. The referral form of Pt #6 was reviewed on 1/25/12. It indicated Pt #6 was referred to the Hospital from another Hospital ED on 1/7/12 with "Came yesterday morning... benzodiazepine/ cocaine positive, suicidal ideation, rough week, all possessions stolen on bus... in Critical Care Unit since yesterday... Reason for denial: Acuity."

13. The referral form of Pt. #7 was reviewed on 1/25/12 . In Indicated Pt. #7 was referred to the Hospital form another Hospital ED on 1/8/12 with need of med adjustment, profoundly retarded, blind. Reason for denial: Not appropriate for program given information on DD psych units.

14. The referral form of Pt #9 was reviewed on 1/25/12. It indicated Pt #9 was referred to the Hospital form another Hospital ED on 1/8/12 with "residential group home, homicidal client with knife; paranoid toward staff had to call police to disarm, disorganized, angry outbursts, hyper, doesn't need to sleep... Reason for denial: Patient not suicidal/ homicide does not meet criteria."

15. The referral form of Pt #10 was reviewed on 1/25/12. It indicated Pt #10 was referred to the Hospital form another Hospital ED on 1/8/12 with "... told family- suicidal ideation- gun- shoot self in head- impulse problems- unkept- relapsed meth... manic- leaving home for a couple days- using crystal meth... Reason for denial." The reason for denial was blank.

16. During a staff interview, conducted with the Director of Risk Management on 1/25/12 at 3:00 PM, the above findings were confirmed.