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.

WESTCHESTER MEDICAL CENTER 100 WOODS RD VALHALLA, NY 10595 May 22, 2017
VIOLATION: RECIPIENT HOSPITAL RESPONSIBILITIES Tag No: A2411
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review, and interview, it was determined that the facility did not comply with Emergency Medical Treatment and Active Labor Act (EMTALA).
This became evident by the facility's failure to accept an appropriate transfer patient who was en-route to the facility via EMS. This was finding was evident in one (1) of 20 records reviewed. (Patient #1).

Findings:

Review of the facility's Call Log revealed that on 05/14/2017 at 07: 57 PM, Patient #1 was logged in for transfer.

Review of the "Transfer Certification" from the sending facility, revealed that on 05/14/2017, at 11:37 AM, Staff A, Psychiatrist at this facility, accepted the transfer of Patient #1 from another facility. The documentation stated that on 05/13/2017, Patient #1 presented at the sending facility with suicidal ideation. The patient did not want to stay in that facility and accepted an offer for transfer to Westchester Medical Center (this facility). The sending physician had a conversation with the attending physician at this facility who agreed to accept the patient.
Documentation in the facility's Call Log revealed that on 05/14/2017, the transfer of Patient #1 was "Denied Due Administrative Review," while the patient was en-route via EMS to the facility. The patient was re-routed back to the sending facility from which he was discharged the same day.


During an interview with Staff B, Psychiatrist, Medical Director, on 05/22/2017 at 09:38 AM, he stated that on 05/14/2017, he made an administrative call to the facility. Staff A, Psychiatrist, informed him that in the morning a resident accepted a transfer of Patient # 1 from another facility. Staff B recalled the patient from a prior admission, and said that he felt threatened. He re-called that during the previous patient's admission on 05/10/2017, patient was opioid and benzodiazepines dependent. Prior to the admission, the patient signed out against medical advice (AMA) from a drug rehabilitation program at another hospital. Staff B said that he inquired what made the patient sign off the treatment, and the patient's response was that he felt he needed benzodiazepines. Staff B stated that Patient #1 threatened him with bodily harm and requested to be discharged . The patient was diagnosed with [DIAGNOSES REDACTED]. Staff B stated, "the patient was not psychotic or manic and his complaints of suicidal ideation appeared to be designed for secondary gain of being in the hospital and obtaining benzodiazepines...It is a judgement call" Staff B stated,and he felt that Patient #1 would not be able to establish a therapeutic alliance. He said, "He was not suicidal in the first place. I did not think that this patient is appropriate for us. This facility does not provide a rehabilitative treatment. It was really a substance abuse and anti-social personality disorder issue." An hour later, Staff B received a phone call from Staff A who informed him that the patient was diverted back to the sending hospital.


During interview on 05/22/2017, at 10:27 AM, Staff A, Psychiatrist at Behavioral Health, recalled that on 05/14/2017, she received an administrative phone call from Staff B, Psychiatrist, Medical Director, during which she informed Staff B of the incoming accepted transfer from another facility. Staff A stated that they discussed the case and decided that "it is best not to transfer the patient." As per staff A, the decision was reached based on clinical judgement of Staff A, Psychiatrist and Staff B, Psychiatrist, Medical Director, who reported a previous encounter with Patient #1. She said that she called the transferring facility, but the patient was already en-route. She
contacted EMS that were providing the transfer service to Patient #1, and asked whether it is possible to return the patient to the sending facility. She was assured that if the sending facility accepts the patient back, there would not be any problem.
Patient # 1 was diverted back to sending hospital while en-route to Westchester Medical Center.


On 05/22/2017, at 11:15 AM, an interview was conducted with Staff C, Chief Compliance Officer, who stated that she received an email from a Chief Nursing Officer of the sending hospital with a copy of the transfer documentation attached. Staff C stated that she had a conversation with Staff A, Psychiatrist and Staff B, Psychiatrist, Medical Director, as well as facility's CEO and informed them that she is going to report EMTALA violation.
Staff C stated, "MDs tried to state their case, but the transfer was accepted and we had to take the transfer until the patient gets here." Our Policy states,"' we do not accept if we lack capacity or capability.'"


Review of facility's policy, "Transferring of Patients From Other Health Care Facilities, Mental Health Clinics, And Residential Agencies to the Psychiatric Emergency Department (PSY-ED) For Admission Evaluation," Revised November 2014, states "The Hospital will not refuse to accept an appropriate transfer or an individual who requires specialized capabilities or facilities of the Hospital, if the Hospital has the capacity and capability to treat the individual."