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GATEWAY REGIONAL MEDICAL CENTER 2100 MADISON AVENUE GRANITE CITY, IL 62040 March 19, 2013
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on a review of a review of Hospital Policies and Procedures, a review of the Resource Center Communication Log, a review of "Helpful Hints for Involuntary Paperwork", and staff interview, it was determined the Hospital failed to ensure compliance with CFR 489.24
Findings include:

1. The Hospital failed to accept involuntary transfers of patients from a referring hospital to provide specialized services for psychiatric care in which the recipient hospital had beds available.
See deficiency cited at A-2411.
VIOLATION: RECIPIENT HOSPITAL RESPONSIBILITIES Tag No: A2411
Based on a review of a review of Hospital Policies and Procedures, a review of the Resource Center Communication Log, a review of "Helpful Hints for Involuntary Paperwork", and staff interview, it was determined the Hospital failed to accept involuntary transfers of 14 of 15 patients for involuntary admission for psychiatric care and services when beds were available.
Findings include:

1. A review of the Hospital Policies and Procedures related to admission criteria for Behavioral Health Services was reviewed during the survey. The policy titled "Emergency Admission by Certification," dated 11/01/12, indicates under "Departmental Policy, In accordance with the Illinois Mental Health and Disabilities Code 405 ILCS 5/CH III Article VI, an emergency admission by certification is initiated for an individual over the age of 18 years who is subject to involuntary admission and in such a condition that immediate hospitalization is necessary for the protection..."

2. A review of the untitled log from the Resource Center from 10/1/12 through 3/18/13 was completed during the survey. The log indicated between 10/2/12 and 3/18/13 there were 15 referrals from areas outside the counties of Bond and Madison for involuntary psychiatric admission that were not admitted for services. The log indicated beds were available on the Behavioral Health Unit on 14 of the 15 dates referrals were made for involuntary admission (10/5/12, 10/11/12, 11/6/12, 11/7/12, 11/12/12, 12/6/12, 1/17/13, 1/25/13, 2 patients on 2/4/13, 2/11/13, 3/4/13, 3/8/13 and 3/16/13).

3. A review of the document titled "Helpful Hints for Involuntary Paperwork " attached to the Patient Transfer Form indicates at bullet point 21, "GRMC can accept Involuntary admission from Madison and Bond Counties."

4. During an interview with the Director, Resource Center (E#1) on 3/18/13 at 1:30 PM, she was asked how the Resource Center is involved in the process of receiving involuntary referrals. During the interview E#1 reported when the referral is received and a bed is available the staff will ask what county they reside and if not in Bond or Madison the staff indicate the patient cannot be accepted. E#1 reported if a bed is available and the patient is in Bond or Madison County, the process begins for triage to ensure the facility can provide the services and the patient meets criteria.

5. During an interview with the Referral Coordinator (E#3) from the Resource Center on 3/18/13 at 4:20 PM, E#3 described the process of receiving referrals for involuntary patients. E#3 indicated when a phone call is received, for involuntary placement for psychiatric services, E#3 screens the calls to ensure the patient being transferred is from Madison or Bond County. E#3 indicated the unwritten policy is to only accept involuntary patients from those two counties, and only if a bed is available.

6. During an interview with the Director of Nursing and Clinical Services, Behavioral Health Services (E#2) on 3/18/13 at 1:30 PM, it was reported in 2002 when the hospital began accepting involuntary patients, the hospital "could not get a States Attorney or Judge" to complete the process for legal representation of the patient. E#2 reported there is no policy indicating the hospital only accepts involuntary psychiatric patients from Bond or Madison County but "due to the legal issues, staff know we cannot accept them."

7. During a telephone interview with the Medical Director of Behavioral Health (E#6) on 3/19/13 at 12:00PM, when E#6 was asked about the policy regarding the acceptance of patients from specific counties, E#6 reported it was E#6's "impression that we take involuntary patients from the counties in the catchment area, when the court will come to see them." The Director of Nursing and Clinical Services, Behavioral Health Services (E#2) who was present during the telephone interview verified the catchment area as Bond and Madison counties.