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.

ST LUKES HOSPITAL 915 EAST 1ST STREET DULUTH, MN 55805 May 5, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on observation, interview, and document review, the hospital failed to ensure compliance with requirements at 42 CFR 489.24 as evidenced by the deficient practice cited at 42 CFR 489.24(f).
VIOLATION: POSTING OF SIGNS Tag No: A2402
Based on observation, interview, and document review, the hospital failed to post sufficient signage in the Emergency Department (ED) that specified the rights of patients with emergency medical conditions and women in labor.

Findings include:

Observations of the hospital's ED on 05/05/16 at 9:50 a.m. established that the hospital has two patient waiting areas, one on each side of the patient check-in desk. The hospital's only EMTALA signage for patients in the waiting rooms was posted on a wall behind the check-in desk, which was not visible to patients in either waiting room. There was no EMTALA signage in either patient waiting room.

RN/F was interviewed on 05/05/16 at 10:00 a.m. RN/F did not know what the average patient waiting time was in in the waiting rooms but stated it was "quite lengthy." RN/F stated she was aware that EMTALA signage needed to be posted in locations such as waiting rooms, where it was easily noticed by all patients waiting for medical screening examinations.

The hospital's EMTALA policy, dated December 2015, indicated "Signs are posted in conspicuous locations advising individuals of their rights to receive an MSE (medical screening examination) and treatment regardless of ability to pay. Signs are posted in the Emergency Department, the Birthing Center, the hospital entrances, admitting areas, waiting rooms, and treatment areas. The wording is clear and simple, and written in language that can be understood by the population served by the hospital. The type of signs is large enough to be easily read."
VIOLATION: RECIPIENT HOSPITAL RESPONSIBILITIES Tag No: A2411
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and document review, the recipient hospital refused to accept a patient in transfer on 04/26/16 when the recipient hospital had the capacity and capability to treat the patient, for 1 of 1 patients reviewed (P1), who required transfer from a referring hospital for inpatient psychiatric admission.

Findings include:

The referring hospital's medical record indicated that P1 presented to their ED, voluntarily, on 04/21/16 with active suicidal ideation. P1 sought professional help for thoughts of either cutting or shooting herself. P1 had a lengthy past psychiatric history requiring prior inpatient hospitalization s for suicide attempts, including stabbing herself in the abdomen. When P1 came into the ED on 04/21/16, P1 was very depressed related to some recent personal domestic issues. P1 had a suicide plan and didn't "want to live any more." P1 also had a substance use disorder and was currently receiving Methadone for recent methamphetamine abuse. P1 was evaluated by Medicine, Crisis staff, and Psychiatry. It was determined that P1 needed inpatient psychiatric treatment for acute suicidal ideation with a plan, but the referring hospital had no inpatient psychiatric beds available. P1 was kept in the referring hospital's ED under close observation while crisis staff attempted to locate an inpatient psychiatric bed at another facility. Crisis staff contacted 16 facilities without any success to find an inpatient psychiatric bed for P1, as the inpatient psychiatric census was full at all facilities contacted. P1 remained in the referring hospital's ED through 04/26/16, at which time an inpatient psychiatric bed was available at the recipient hospital. Crisis staff contacted the recipient hospital on [DATE] about the available bed. The recipient hospital refused to accept P1 in transfer. The recipient hospital told the referring hospital that P1 had been in the referring hospital's ED longer than 30 hours which exceeded the recipient hospital's policy and admission criteria for inpatient psychiatric hospitalization . After the recipient hospital refused to accept P1 in transfer, crisis staff contacted 17 additional facilities on 04/26/16, including facilities in nearby States, but none had any inpatient psychiatric beds open. Crisis staff continued to contact numerous facilities every day P1 remained in the referring hospital's ED, in attempt to obtain an inpatient psychiatric bed for P1, but all attempts were unsuccessful due to full patient censuses. P1 remained in the referring hospital's ED on a voluntary basis, through 05/02/16, at which time an inpatient psychiatric bed became available at the referring hospital and P1 was transferred from the ED to the referring hospital's inpatient psychiatric unit. P1 remained actively suicidal at the time of inpatient admission on 05/02/16.An interview with RN/F was conducted on 05/05/16 at 9:35 a.m. RN/F stated that referring hospitals contact an intake specialist at the recipient hospital regarding the transfer of a patient from the referring hospital for inpatient admission to a specific Service at the recipient hospital. The intake specialist connects the referring hospital to the appropriate Service Discipline. Referrals regarding patients with medical issues are directed to the specific inpatient Medicine Discipline and a physician from that Discipline determines if the patient can be accepted in transfer. Referrals regarding patients with psychiatric needs are directed to the inpatient mental health unit and the inpatient mental health unit staff determine if the patient can be accepted in transfer.

Observations of the recipient hospital's inpatient mental health unit on 05/05/16 at 10:35 a.m. established that the secured unit has the capacity to serve 22 inpatients with psychiatric needs, devoting fifteen beds to patients with acute illnesses and seven bed to patients with less acute needs.

The recipient hospital's Master Diversion Log and Master Diversion Worksheet indicated that the recipient hospital had no psychiatric beds available on the inpatient mental health unit from 7:07 p.m. on 03/31/16 to 1:17 p.m. on 04/26/16, at which time diversion ended. Inpatient mental health unit beds were available at the recipient hospital on [DATE] for approximately 3.5 hours, before the recipient hospital went back on diversion at 4:50 p.m. on 04/26/16 for inpatient admissions to the mental health unit. The Master Diversion Log indicated that the recipient hospital had no psychiatric beds available from 4:50 p.m. on 04/26/16 to 2:55 p.m. on 04/28/15.
The recipient hospital's inpatient midnight census for the mental health unit on 04/26/16 was 17 patients.
The recipient hospital's inpatient midnight census for the mental health unit on 04/27/16 was 18 patients.
The recipient hospital's inpatient midnight census for the mental health unit on 04/28/16 was 16 patients.
The recipient hospital's inpatient midnight census for the mental health unit from 04/26/16 - 04/28/16 indicated that the patient census fell below the unit's capacity on all dates. This information conflicted with the recipient hospital's Master Diversion Log and Master Diversion Worksheet, which indicated lengthy periods when inpatient admissions to the mental health unit were diverted from 04/26/16 - 04/28/16 because no beds were available.
The recipient hospital's mental health unit intake log regarding patient transfers from referring facilities indicated that mental health unit staff received two transfer requests for inpatient admission on 04/26/16. The log indicated that the mental health unit accepted one patient for inpatient admission and declined admission to the other patient because the patient had been "in ER for 40 hours." The name of the patient who was refused admission was not listed, but the gender of the patient was identified as well as the referring hospital's name, which established that it was not P1. Neither P1's data nor request for transfer was listed on the log.

An interview with RN/G was conducted on 05/05/16 at 10:35 a.m. RN/G stated that the mental health unit keeps a log that tracks transfer requests for inpatient psychiatric admissions from referring facilities. The log includes the date /time, patient name, whether the patient's transfer was accepted or declined, the name of the sending hospital, and the initials of the staff member who took the call. All mental health unit nurses have the authority to speak with a referring hospital about a potential inpatient psychiatric admission to the mental health unit. All mental health unit nurses have the authority to accept or decline a patient's transfer and inpatient admission to mental health, based on the hospital's policy and transfer criteria. Not all mental health nurses utilize the log appropriately. The log is sometimes incomplete with patient data. The log does not always include every transfer request from referring facilities. RN/G confirmed that two patients were declined admission to the mental health unit on 04/26/16, P1 and another unidentified patient, because both patients had been in the transferring hospitals' EDs longer than 30 hours, which exceeded the recipient hospital's inpatient admission policy regarding transfers of psychiatric patients. RN/G did not know why the midnight mental health unit census reports from 04/26/16 - 04/28/16 conflicted with information on the Master Diversion Log, deterring inpatient admissions to the mental health unit when the patient census was 16 - 18 patients and the unit's capacity is 22 patients. RN/G stated it was possible that all 15 beds dedicated for patients with acute mental health illnesses were full. Typically, mental health unit staff reassess inpatients in the acute beds to determine if any inpatients can be moved to the less acute beds, in order to accommodate the need for additional inpatient admissions when patients with acute mental health illnesses present to the recipient hospital's ED or to the ED of a referring hospital. RN/G did not know whether mental health unit staff reassessed inpatient needs on 04/26/16 - 04/28/16 for possible adjustments to accommodate potential inpatient admissions.

The recipient hospital's policy Inpatient Mental Health Services Admission Criteria, dated March 2015, indicated "If a patient is an external transfer, the sending physician must communicate with the provider on-call and that provider must agree to accept the patient prior to admission. We are unable to accept patients in involuntary transfer from outside facilities who have been held against their will for greater than 30 hours exclusive of weekends and holidays...Adults [AGE] and above may be admitted ...Patients admitted to the Mental Health Unit will meet one or more of the following: (a.) Demonstrate the presence of a psychiatric illness with significant risk of suicidal and/or homicidal behavior that could lead to danger to self and others. (b.) Documented failure of outpatient treatment including: 1. Symptoms which are unmanageable on an outpatient basis. 2. Lack of expected therapeutic response or necessary compliance with prescribed medications. 3. Inability to care for self due to psychiatric illness. (c.) Initiation of psychotropic medication treatment requiring intensive monitoring for side effects or toxicity."

The recipient hospital's EMTALA policy, dated December 2015, indicated "Receiving transfers - St. Luke's is obligated to accept an appropriate transfer of an individual with an unstable EMC (emergency medical condition) if the patient requires the specialized capabilities available at St. Lukes that are not available at the sending hospital and St. Lukes has the capacity to treat the patient. Acceptance of a patient with an unstable EMC will not be delayed to receive or verify financial information."

The recipient hospital's policy regarding the acceptance of transfer patients from referring facilities for inpatient admission to the mental health unit did not conform to EMTALA requirements.