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.

CEDAR SPRINGS BEHAVIORAL HEALTH SYSTEM 2135 SOUTHGATE RD COLORADO SPRINGS, CO Oct. 27, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interviews and document review, the facility failed to comply with the Medicare provider agreement, as defined in 489.24, related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

FINDINGS:

1. The facility failed to meet the following requirements under the EMTALA regulation:

Tag A2406 - Medical Screening Exam

Based on interviews and document review, the facility failed to ensure an appropriate Medical Screen Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation was provided by qualified medical personnel (QMP) in consultation with a phsycian in 8 of 9 records reviewed for patients who presented to the facility for emergency evaluation and were not admitted . (Patients #3, #5, #8, #11, #13, #15, #18, and #20).

Tag A2409 - Appropriate Transfer

Based on record review, the facility failed to ensure patients requiring a higher or specialized level of care were transferred appropriately pursuant to EMTALA (Emergency Medical Treatment And Labor Act) for 2 of 2 patients transferred reviewed (Patients #11 and #17).

Tag A2411 - Recipient Hospital Responsibilities

Based on interview and record review, the facility failed to accept responsibility for 1 of 6 patients (Patient #4) referred, accepted and transferred to the facility for specialized psychiatric capabilities resulting in a delay in treatment.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on interviews and record review, the facility failed to ensure an appropriate Medical Screen Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation was provided by qualified medical personnel (QMP) in consultation with a phsycian in 8 of 9 records reviewed for patients who presented to the facility for emergency evaluation and were not admitted . (Patients #3, #5, #8, #11, #13, #15, #18, and #20).

This failure created the potential for delays in diagnosis and treatment of emergency medical conditions.

FINDINGS:

POLICY

According to the policy, titled Emergency Screen and Patient Transfer and Physician Availability, the purpose of the policy is to ensure that individuals presenting to the facility requesting emergency medical services are assessed, stabilized and/or transferred. Qualified medical personnel (QMP's) will be designated by the Governing Board to provide an initial screening/assessment and to confer with a physician concerning the existence of an emergency medical condition.

A member of Assessment and Referral or a nurse will assess individuals presenting to the facility requesting emergency treatment for a psychiatric/substance abuse condition. A nurse will assess individuals presenting for emergency treatment of a medical/surgical condition or medically compromised psychiatric/substance abuse condition. The results of all assessments conducted will be communicated to the physician on-call.

Depending upon the findings of the assessment and the needs of the individual, the physician or Registered Nurse (RN) (after conferring with the physician) will inform the individual of the risks and benefits of the recommended treatment and/or transfer.

1. The facility failed to ensure all patients who arrived at the facility seeking emergency medical treatment received a medical screening examination by a QMP, in consultation with a physician, to determine if an emergency medical condition existed.

a) Review of the EMTALA Log, dated 06/09/16, showed Patient #3 presented to the facility at 1:00 p.m. by car. The log noted the patient left at 2:10 p.m. by private auto as s/he was referred to a hospital emergency department (ED) for medical clearance.

Review of a Needs Assessment, dated 06/09/16 at 1:30 p.m. and completed by Crisis Evaluator #1 (CE, Licensed Professional Counselor, LPC), noted the patient had high blood pressure and "there may be health concerns." CE #1 documented 'per nurse' the patient was referred to an ED for high blood pressure.

According to the Needs Assessment and an Additional Ebola Virus Screening Form, dated 06/09/16, CE #1 documented the patient's blood pressure was 184/122. The physician was to be notified if a systolic blood pressure was greater than 180 or diastolic was greater than 100.

However, there was no documentation a registered nurse (RN) assessed Patient #3 or that a physician was contacted regarding the patient's high blood pressure.

Additionally, review of the Needs Assessment showed no evidence the physician was contacted and consulted with the results of the assessment to determine if an emergency medical condition existed. Specifically, the Disposition section, which would indicate the assessment was reviewed with a physician was left blank.

b) Review of the EMTALA log, dated 06/11/16, showed Patient #5 arrived at the facility at 12:00 p.m. by private car. According to the log, the patient left the facility at 2:00 p.m. by car as s/he "declined" treatment. No resources were offered.

Review of the Needs Assessment Level of Care Determination section, dated 06/11/16 at 1:00 p.m. and completed by CE #2 (Licensed Professional Counselor), showed the patient was gravely disabled as evidenced by hallucinations and paranoia. Additionally the assessment summary noted the patient "appears to be responding to internal stimulus or experiencing thought blocking as evidenced by difficulty responding to basic questions." The patient was accepted by a physician for psychiatric stabilization. However, the note stated the patient "decided to leave" as no M-1 (Emergency Mental Illness Report and Application) was in place at the time.

Review of M-1 documentation, dated 06/11/16, showed CE #2 documented the patient believed people were stalking him/her and trying to kill him/her. The patients emotional reactions were noted as sad, suspicious, illogical, rambling, hearing voices and suicidal thoughts. CE #2 noted the patient was hearing voices, believed the people stalking him/her were tying to kill him/her and the patient was "unable to make effective decisions about safety." CE #2 signed the M-1 hold but there was no time documented.

There was no documentation to show why the patient was allowed to leave the facility after s/he was determined to be gravely disabled, met criteria for a M-1 hold and was accepted for admission by the physician. Additionally, there was no documentation CE #2 communicated with the physician regarding Patient #5's decision to leave the facility.

c) Review of the EMTALA Log, dated 10/23/16, showed Patient #8 presented to the facility at 1:00 p.m. by car. The log noted the patient left at 2:30 p.m. by private auto as s/he was referred to outpatient services.

According to the Needs Assessment, dated 10/23/16 at 1:15 p.m., Patient #8 was brought in by his/her parents due to out of control behaviors. CE #6 (Licensed Professional Counselor) completed the Needs Assessment and documented the parents were asking for admission; however Patient #8 did not "meet criteria for acute at this time."

There was no documentation a physician was consulted with the results of CE #6's assessment to determine if an emergent medical condition existed which required immediate treatment.

d) Review of Patient #11's record showed a Needs Assessment, dated 10/06/16 at 8:10 a.m. and completed by CE #6. According to the documentation no assessment was completed as the patient was found in the truck with multiple pill bottles and was sent out immediately for medical clearance.

According to an Observation Check Log/Seclusion and Restraint Log, Patient #11 was restless and pacing during the time s/he was at the facility (approximately 1.25 hours).

Review of a Screening Form, dated 10/06/16 at 8:35 a.m., completed by CE #6 revealed the patient was experiencing heart palpitations (feelings of having rapid, fluttering or pounding heart), high blood pressure, difficulty breathing and confusion.

There was no documentation a physician or registered nurse was notified and assessed the patient.

Review of the Patient Transfer Order/Memorandum of Transfer, completed by CE #6 at 8:52 a.m., showed the patient was to be transferred to an acute care hospital via ambulance.

However, there was no documentation a physician or registered nurse was consulted the entire time Patient #11 was at the facility (approximately 1.25 hours) to conduct an appropriate medical screening examination and provide any necessary stabilizing treatment while an appropriate transfer was effected.

e) Similar findings were identified for Patient's #13, #15, #18, and #20 in which the patients presented to the facility for an emergency evaluation, were not admitted to the facility and in which no coordination with the physician occurred.

f) During an interview with Registered Nurse #3 (RN, Nursing Service Coordinator) on 10/26/16 at 3:00 p.m., s/he stated if a patient came to the facility for an assessment and needed to go to an emergency department they would call 911. RN #3 stated s/he would not necessarily call a physician.

g) During an interview, on 10/27/16 at 9:13, CE #6 stated s/he provided employees with EMTALA training throughout the facility. CE #6 stated the determination of an emergent medical condition was made by the assessor (crisis evaluator or registered nurse). CE #6 stated if the patient's complaint was medical in nature they would all a RN. If the patient had a high blood pressure they would call immediately for a transfer. CE #6 stated the evaluator would not call the psychiatrist/physician.

h) During an interview, on 10/27/16 at 10:38 a.m., Director of Nursing #7 (DON) stated Assessment & Referral staff (A&R, crisis evaluators) could do the initial screening and vital signs for patient's presenting for an emergent evaluation. DON #7 stated the screening should be reported to the psychiatrist/physician and the report should have been documented in the patient's record.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review, the facility failed to ensure patients requiring a higher or specialized level of care were transferred appropriately pursuant to EMTALA (Emergency Medical Treatment And Labor Act) for 2 of 2 patients transferred reviewed (Patients #11 and #17).

Findings

POLICY

According to the policy, Emergency Screen and Patient Transfer and Physician Availability, the purpose of the policy is to ensure that individuals presenting to the facility requesting emergency medical services are assessed, stabilized and/or transferred. Qualified medical personnel (QMP's) will be designated by the Governing Board to provide an initial screening/assessment and to confer with a physician concerning the existence of an emergency medical condition.

A member of Assessment and Referral or a nurse will assess individuals presenting to the facility requesting emergency treatment for a psychiatric/substance abuse condition. A nurse will assess individuals presenting for emergency treatment of a medical/surgical condition or medically compromised psychiatric/substance abuse condition. The results of all assessments conducted will be communicated to the physician on-call.

Depending upon the findings of the assessment and the needs of the individual, the physician or Registered Nurse (RN) (after conferring with the physician) will inform the individual of the risks and benefits of the recommended treatment and/or transfer.

If the physician responsible for the individual determines that a transfer is in the best interests of the individual, the following steps must be taken:

The physician, RN, Nursing Supervisor, or Crisis Evaluator shall secure agreement from a receiving facility to accept the patient and provide appropriate treatment. The date, time, and name of the contact person making the agreement must be documented on the individual's record of care and transfer record.

The physician (or the RN or Crisis Evaluator in consultation with the physician when the physician is not in-house) must document in the patient care record that the benefits of the transfer outweigh the risks. This determination must be explicitly written into the record and signed and cannot simply be inferred from the findings in the record. The written determination shall include there reason for the transfer and a summary of the risks and benefits upon which the determination was based. If the determination is documented by the RN in consultation with the physician, the determination must also be signed by the physician within 72 hours.

1. The facility failed to complete an appropriate transfer for patients requiring a higher level of care.

a) Review of Patient #11's record showed a Needs Assessment, dated 10/06/16 at 8:10 a.m. and completed by Crisis Evaluator #6 (CE, Licensed Professional Counselor, LPC). According to the documentation no assessment was completed as the patient was found in the truck with multiple pill bottles and was sent out immediately for medical clearance.

According to an Observation Check Log/Seclusion and Restraint Log, Patient #11 was restless and pacing during the time s/he was at the facility (approximately 1.25 hours).

Review of a Screening Form, dated 10/06/16 at 8:35 a.m., completed by CE #6 revealed the patient was experiencing heart palpitations (feelings of having rapid, fluttering or pounding heart), high blood pressure, difficulty breathing and confusion.

Review of the Patient Transfer Order/Memorandum of Transfer, completed by CE #6 at 8:52 a.m., showed the patient was to be transferred to an acute care hospital via ambulance. However, the portion of the form, titled Physician Name Approving Transfer, was left blank. Additionally, there was no documentation of risks or benefits of the transfer and signature of the transferring physician. There was no documentation the facility communicated with the receiving facility regarding Patient #11.

Further, there was no documentation a physician or registered nurse was consulted and evaluated Patient #11 during the entire time s/he was at the facility to assess the patient and provide stabilizing treatment while an appropriate transfer was effected.

b) Review of the EMTALA log, showed Patient #17 (MDS) dated [DATE] at 8:40 a.m. and was transferred by ambulance for medical clearance at 10:00 a.m.

According to the Patient Transfer Order/Memorandum of Transfer the patient was being transferred for a blood pressure of 189/97 for medical clearance prior to admission to the psychiatric hospital. However, there was no documentation of risks or benefits of the transfer and no signature from the transferring physician certifying and authorizing the transfer to a higher level of care.
VIOLATION: RECIPIENT HOSPITAL RESPONSIBILITIES Tag No: A2411
Based on interview and record review, the facility failed to accept responsibility for 1 of 6 patients (Patient #4) referred and transferred to the facility for specialized psychiatric capabilities resulting in a delay in treatment.

Findings:

POLICY

According to the policy, titled Restraint and Seclusion, the purpose of the policy is:
-To establish that restrain and/or seclusion/locked quiet room may be used only as an emergency measure to protect the patient from injury to self or others.

Clinical Justification
-The use of restraint and seclusion/LQR poses an inherent risk to the physical safety and psychological well being of the patient and staff. Therefor restraint and seclusion/LQR are used only in an emergency where there is an imminent risk of a patient physically harming himself/herself, or others, including staff. Nonphysical, low level interventions are the first choice as an intervention unless safety issues demand an immediate physical response.

1. The facility failed to allow a patient that had already been accepted as a transfer from another hospital for specialized services, to remain at the facility and receive treatment.

a) Patient #4 was brought to the referring hospital's emergency department on 6/7/16 by law enforcement. While at the referring hospital, it was determined that Patient # 4 had suicidal ideations, paranoia and post traumatic stress disorder and required specialized psychiatric services not provided at that hospital. S/he was found to be a danger to self or others and a mental heath hold was placed on Patient #4 at 8:30 p.m. on 6/8/16.

On 6/9/16, the facility was contacted by the referring hospital, approximately 70 miles away, to determine if the facility had the specialized capabilities and bed capacity to accommodate Patient #4. At 1:49 p.m., Crisis Evaluator #5 (CE) accepted the transfer of Patient #4 (after consulting with the on call psychiatrist). Registered Nurse #4 (RN) received a nurse to nurse report from the referring hospital at 2:15 p.m. on 6/9/16.

b) Patient #4 was transported by ambulance to the recipient hospital and arrived at approximately 6:45 p.m. on 6/9/16. Patient #4 had been sedated and placed in restraints during transport. Upon arrival at the recipient hospital, while moving the patient via stretcher into the facility, RN #4 stopped the EMS personnel and denied completion of the transfer. The Nursing Service Coordinator (RN #3) was contacted, came to where Patient #4 was being held and confirmed refusal of the transfer due to the fact that Patient #4 had received sedation and was in restraints. Patient #4 was returned to the ambulance by the EMS personnel, who began the transport back to the referring hospital.

c) RN #3 was interviewed on 10/26/16 at 3:00 p.m. S/he described the usual course for patient transfers was for clinical staff in the Assessment and Referral (A&R) office to gather the pertinent clinical history, current assessment and status of the patient from the referring facility. A&R staff then consulted with the psychiatrist on call to determine whether the patient would be accepted or denied. If the patient was accepted, a nurse to nurse report would take place and once the patient arrived on the hospital grounds, they would go directly to the unit where the patient was to be admitted .

RN #3 was asked if s/he recalled the occurrence on 6/9/16 involving Patient #4. S/he recalled the events and replied that s/he was called to the front lobby of the housing unit where Patient #4 was being held. RN #3 stated "when I got to the lobby, the patient was on a stretcher, restrained, breathing heavy and was out of it." RN #3 informed the EMS personnel that the facility did not care for patients requiring physical restraints and refused to accept the patient. When asked if the facility ever accepted restrained patients for admission, RN #3 replied "not generally, we will only take them if they come in shackles from the sheriffs' department."

RN #3 stated that Patient #4 was in the lobby "about 10 minutes." RN #3 indicated that a medical screening examination had not been performed on Patient #4 and that vital signs had not been obtained. RN #3 stated s/he had not evaluated Patient #4 to determine if restraints were still required because "he was somnolent (sleepy)." RN #3 went on to say, "I wouldn't have returned the patient without the doctor's approval." S/he indicated that patient encounters, assessments and communications with the physician would be documented in the Progress Notes portion of the patient's medical records.

RN #3 stated s/he was considered a Qualified Medical Personnel as defined in the EMTALA regulations and that all the Registered Nurses were. "A test was taken yearly on EMTALA." When asked if s/he felt the facility fulfilled the EMTALA expectations concerning Patient #4 as a recipient hospital, RN #3 stated "yes, we didn't sign for the patient" and "we didn't accept the patient." This was in contrast to the record completed by CE #5 which documented that after consultation with the on call psychiatrist, Patient #4 was accepted for transfer on 6/9/16 at 1:49 p.m.

The 6/9/16 facility record for Patient #4 was reviewed. The Evaluation form completed by CE #5 indicating physician consultation and acceptance of the patient, a Nurse to Nurse Report form completed by RN #4 on 6/9/16 at 2:15 p.m. and a Patient Information Sheet were the only documents in the record. There was no documentation of an assessment of Patient #4 by either RN #3 or RN #4 when s/he arrived at the facility. There were no Progress Note entries completed by RN #3 on 6/9/16 describing the encounter with Patient #4, communication with the EMS personnel, nor any communication with the psychiatrist on call.

Specifically, there was no documentation to show Patient #4 arrived at the facility on 6/9/16 and refused treatment.