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.

HIGHLANDS BEHAVIORAL HEALTH SYSTEM 8565 S POPLAR WAY LITTLETON, CO 80130 Nov. 6, 2012
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on medical record review, staff interviews, and review of facility documents, the facility failed to comply with the Medicare provider agreement as defined in 489.20 and 489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

Findings:

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

Tag A 2411 Recipient Hospital Responsibilities
The facility failed to admit and treat a patient upon presentation to the facility, despite that the facility had accepted the patient and determined they had capacity and capability to treat the patient's specialized medical needs.
VIOLATION: RECIPIENT HOSPITAL RESPONSIBILITIES Tag No: A2411
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, staff interviews, and review of facility documents, the facility failed to admit and treat a patient upon presentation to the facility in 1 (#20) of 20 sample medical records, despite that the facility had accepted the patient and determined they had capacity and capability to treat the patient's specialized medical needs. Instead, the facility refused admission and the patient was transported back to the transferring facility, which was over 100 miles away and located in the mountains. This failure created the potential for a significant negative patient outcome, such as an exacerbation in psychiatric symptoms which necessitated the transfer.

The findings:

1. Sample patient #20 was determined in need of specialized psychiatric care by the transferring facility. The psychiatric facility staff and physician accepted the patient for treatment. However, after transport to the psychiatric facility, a facility staff member refused admission due to lack of documentation and the patient had to be transported back to the transferring facility, despite the risk of inclement weather and that the patient had several comorbidities, including the need and use of continuous oxygen.

a) Medical Record Review

A "Comprehensive Assessment Tool" was completed on 10/24/12 for a planned transfer of 10/25/12. The form was completed and signed by a Licensed Professional Counselor on 10/25/12 at 20 minutes after midnight. The form's documentation stated the assessment had been reviewed with the Chief Medical Officer physician on 10/24/12 at 10:30 p.m. The form stated the patient was a direct admit and would be accompanied by a sheriff from the transferring facility/ city. Documentation stated the patient was brought to the emergency room at the transferring facility for acute psychosis, including auditory and visual hallucinations. The form stated the patient had a history of psychiatric issues and had recently been treated at another inpatient psychiatric facility. The form stated the patient had been placed on a M1 72 hour mental health hold by staff at the transferring facility after a psychiatric evaluation. The form stated the patient's medications and current medical/physical problems, which included seizure disorder, COPD, arthritis, heart murmur, diabetes, hypertension, neuropathy, and 4 liters of continuous oxygen. The form stated, in part, "Pt is gravely disabled due to psychotic sx [symptoms] and oblivious to dangerousness. She is non-compliant c [with] O.P. [outpatient] healthcare plan. Placed on M1 for immediate psych admission, for safety, obs, medication eval, and sx stabilization."

The "Admissions Tracking Form" for the patient was reviewed. The form contained a list of several task items, which were initialed by the staff member once completed. The item "MD Review for Admission" was initiated by the same Licensed Professional Counselor (LPC). Additional task items were initialed and the LPC had began the patient's medical record documents, included a High Risk/ High Alert Notification which stated the patient's medical issues and oxygen needs. The latter form was dated 10/24/12 and timed 11:10 p.m.

The "Pre-Admission Nurse to Nurse Report" was reviewed. The form was began on 10/24/12, however, contained documentation from the first attempted admission as well as the second successful admission. For the first attempted admission, the form indicated report was received from a nurse at the transferring facility on 10/24/12 at 11:25 p.m. The form documentation stated the patient would be admitted to the Adult I unit and to room 2111A. The form documentation stated the patient's past medical history in detail, home medications, recent vital signs, recent lab results, psychiatric symptoms, that the patient was on oxygen, and the form was signed by a nurse on 10/24/12 at 11:25 p.m. The back of the form contained an area for free-hand "Presenting Problem" documentation. An unsigned note, time 2:00 a.m., was confirmed by the Chief Clinical Officer to have been documented by the floor nurse working that night. It stated, in part: "pt arrived s [without] EMTALA via Sheriff Dept; House Supervisor [illegible documentation] c [transferring facility] to correct the situation; pt returned to [transferring facility] (c full O2 tank & VS WNL) to obtain needed paperwork."

A "Nursing Progress Note" was documented and placed the patient's record. It was dated 10/25, timed "0200 - 0330," and unsigned, though the Chief Clinical Officer confirmed the handwriting was from the Nursing Supervisor who worked that evening. The form documentation stated, in part: "New admit pt for Unit I arrived at front door at approximated 0200. Due to no intake coverage, Nursing Supervisor opened door, noted time of arrival, and checked for 3 legal forms (M1 Hold, Pt Rights, EMTALA). In place of EMTALA there was a 2nd yellow copy of M1 Hold. NS verified c [with] Deputy [officer's name] (transporting pt from [transferring facility and location] that EMTALA form absent. NS consulted experienced LPC/RN [staff's name] on missing EMTALA form. LPC/RN assisted c [with] explanation to Deputy and [transferring facility] hospital personnel re: legal necessity of EMTALA form regarding chain of custody. Deputy agreeable. Pt was offered fluids, snacks, made comfortable in chair. Oxygen tank (from [transferring facility]) empty and tank was exchanged c [facility's] full tank [tank number] for return trip (and round trip back c EMTALA form) due to pt on 2L continuous O2 via NC. VS WNL (92% PaO2, 62 HR, 139/72 BP). NS and LPC/RN spoke to RN, RN supervisor [name] and outpatient Mental Health Personnel [name]. [Transferring facility's mental health staff member, police officer, and transferring facility's nursing supervisor] agreed on a plan of action to: Deputy and 2nd person (unknown name) transport pt back to [transferring facility] where referring dr. would write on EMTALA form and pt would return legally to [facility] (possibly in ambulance for medical necessity). Following initiation of agreed upon plan, NS received 2 more call from [transferring facility] hospital (pt en route back to [transferring facility]) still seeking answers about EMTALA, and blaming [facility] intake for not telling them this was needed. NS explained that it is standard, and not an expectation of Intake personnel to remind hospital/ medical personnel of transport processes. During this post-plan call c [transferring facility's staff] stated that the pt may not be returning to [facility] because they refuse to transport suicidal patients by ambulance. Pt is not suicidal. Pt referred for psychosis. NS informed [transferring facility's staff member] that although the pt is a mental health pt, she is also medical pt requiring continuous oxygen. In addition, [transferring facility's staff member] was informed by NS that we assessed pt's VS and stability and even exchanged her empty oxygen tank to ensure safe transportation back to [transferring facility]. [Transferring facility's staff member] expressed dissatisfaction and wants to talk to another administrator in the morning; but also seemed to understand that there are some system issues c [transferring facility] hospital regarding the safe transport of a medical/ mental health patient. [Receiving facility] expects to receive pt back c appropriate legal forms, as pt has been accepted. However, it is unknown if [transferring facility] will be able to find a mode of transport if Sheriff's Dept is unwilling to re-transport and [transferring facility] hospital policy does not allow for ambulance transport."

Sample patient #20 was finally admitted hours later, on 10/25/12 at approximately 7:00 p.m. The patient's second record, sample record #1, revealed the patient was treated and discharged on [DATE]. The discharge summary, dictated by a physician, stated, in part: "The patient was admitted to Adult Inpatient Unit I for safety, stabilization, and medical management. It is noted that the patient was initially improperly transferred to [the facility] utilizing a sheriff's transport rather than ambulance. During this initial improper transport, the patient was not properly treated with oxygen and her oxygen saturation levels dropped into the 70's. The patient was returned to [transferring facility] for proper medical treatment, as well as proper transport, and she arrived back at [the facility] in proper transport."

b) Facility Documents

The facility's EMTALA Log was reviewed for the date 10/25/12. It stated sample patient #20 arrived at 2:00 a.m. via sheriff's vehicle. It stated the patient had an emergency medical/ psych condition. It stated the patient's departure time was 3:30 a.m. It stated the patient was "Admit I," indicating the patient would be admitted to the Adult I unit, but next to that documentation it stated "return to sending facility." The same day, the patient arrived again, at 7:00 p.m., via EMS. It stated the patient had an emergency medical/ psych condition. It stated the patient departed at 7:15 p.m. and was "Admit I."

The physician on-call list revealed the facility's Chief Medical Officer was on-call for psychiatric care the night of 10/24/12 - 10/25/12.

The Intake Unit's schedule revealed a staff member that was scheduled to work from 10 p.m. to 6:30 a.m. the night of 10/24/12 - 10/25/12 called in sick. Another staff member, the Licensed Professional Counselor, was written in to cover from 12:00 to 1:00 a.m. Additionally, another staff member was written in to be on-call throughout the night hours.

The nursing staffing for 10/24/12 - 10/25/12 was reviewed and found to be appropriate per the facility's staffing matrix.

EMTALA training provided to all staff members working in October 2011, which included the Nursing Supervisor, was reviewed. It was a power point and stated, in part: "Obligation to Accept Transfers - Medicare-certified psychiatric hospitals are considered "hospitals with specialized capabilities." therefore, they must: - Accept appropriate transfers of emergent individuals needing their specialized services when the transferring hospital does not provide those services; - Provide the individuals with necessary stabilizing treatment within the Hospitals' capabilities; and - make the decisions about whether they can treat the individual without delay or regard to the individual's ability to pay. - EMTALA does not allow a hospital to refuse such a transfer just because it is not the closest psychiatric hospital to the transferring hospital."

The facility's policy titled Patient Admission, last reviewed 7/2012, stated, in part: "After the assessment has been completed the Intake Specialist will review the clinical information with the psychiatrist on-call. The psychiatrist will determine the level of care which will be then recommended to the patient."

The facility's Medical Staff Rules and Regulations were reviewed and stated, in part: "All admissions shall be processed through the Intake Department. The admitting physician will provide the prior notice sufficient to process insurance verification and to contact the patient or family so as to arrange for admission in the most efficient and comfortable manner for the patient."

c) Interviews

On 11/6/12 at approximately 8:15 a.m., an interview was conducted with the Nursing Supervisor (NS) who worked the night of 10/24/12 - 10/25/12. When asked what happened that night, s/he stated, "The patient came in. We didn't have an intake person at the time she came in. She came with a Deputy and I noted the time, hold, Rights, and the EMTALA form was missing." The NS was asked if s/he had been contacted from the transferring facility regarding the patient. S/he stated s/he had not been contacted but was informed of the transfer when s/he came on shift that night at 11:00 p.m. "I knew one person was on their way, en-route, but I didn't have specific info," s/he stated. When asked what involvement the NS has with admissions and intake, s/he stated, "My involvement is usually beds, numbers, unit staff coordination. I am looking more at quantity, not at direct info." When asked if s/he had covered the intake position before, s/he stated s/he had at various times but it was rare. S/he stated s/he covered intake that night from 12:30 a.m. to 7:00 a.m. When asked the NS's role in the intake process, s/he stated, "My role in the intake piece is to note the time arrived, take a picture, make sure the three legal forms are in place, and get the patient up to the unit."

The NS was asked further about the patient's missing EMTALA form. S/he stated, "I talked with the Deputy about the form and consulted another person who had done stuff like this, who confirmed it wasn't a completed transfer without that form. The Deputy and me got on live with the other hospital and tried to get things in line for a completed transfer." The NS was asked what was decided. S/he stated, "We talked to a few people with the hospital, the main contact was the Mental Health Provider. All three of us, the Mental Health Provider, me, the Sheriff, agreed with the change in plan: to go back to the facility, doctor to come in and do the EMTALA form, and transfer the patient back to us." The NS was asked what occurred after that. S/he stated, "While with us, we gave her juice, food, and checked her vital signs. Her oxygen tank seemed to be low or almost empty. We replaced it with a full tank and made sure it was ok on her way back. The hospital person, Deputy, and us were all on the same page." The NS was asked about the patient's mental status. S/he stated the patient was alert and oriented but had a couple instances where she was laughing inappropriately and the NS could not ascertain the cause of this behavior. The NS stated the patient was not suicidal. When asked if the patient's vital signs were abnormal, s/he stated, "No. They were all within normal limits and not concerning. Her blood pressure was up a little at 132 systolic and her oxygen was about 90. It was fine." The NS was asked if the patient came with any documents. S/he stated, "They had a folder with some other things like maybe her labs from the hospital." When asked if there was adequate staffing that night on the two adult units, s/he stated, "Yes." The Chief Clinical Officer confirmed there were available beds that night. The NS was asked again about the EMTALA form. S/he stated, "The way I understood it, they never did a form. That is why they contacted a doctor to do one." When asked if a physician to a physician telephone consultation had occurred, s/he stated, "They usually don't necessarily do a doc to doc." When asked why the patient was sent back, s/he stated, "It was an incomplete transfer." The NS was asked if the transferring facility had offered to fax the EMTALA form. S/he stated, "They talked about faxing a copy, but they didn't have the doctor in there and didn't have anything to fax or copy." The NS continued, "I assumed that the doctor wanted to assess her or see her prior to writing the form." The NS was asked if there was anything s/he would have done differently. S/he stated, "I could have called the Administrator-on-call for other ideas." When asked if s/he had spoken with the admitting physician at any time, s/he stated, "No. I was looking at this like it was an incomplete transfer and she wasn't our patient yet." The Chief Clinical Officer was asked if other patients were ever transported via police car. S/he stated they occurred during the day, but were not usually transfers from acute care hospitals. The NS confirmed that the nurse to nurse form was only used by the nursing staff on the floor, that the comprehensive assessment was only used by the intake staff, and that s/he had documented a nursing note regarding the incident.

The Lead Intake Clinician (LIC) was interviewed on 11/6/12 at approximately 9:30 a.m. When asked about that evening, s/he stated she was on-call through-out the night. "We had staff call in sick. I covered part of the night and they could call me in with a walk-in referral." The LIC was asked if s/he had any involvement in this case, to which s/he stated s/he had not. S/he confirmed s/he had not been called all night. The LIC was asked about the usual intake/ admission process. S/he stated the facility gets call from referral centers and emergency departments. S/he stated the intake clinicians get all the patient information and screen them over the phone. S/he continued, "We have them fax the H&P, labs, clinical info, M1 Hold, Rights, nursing notes, and any other documentation. Then we review the info with the psychiatrist and request additional information if needed, like the last medication given. The psychiatrist makes the determination on acceptance. We call the referral back and let them know, obviously checking if we have a bed. Then we call up to our nursing unit and let them know and the sending facility will call to give report, most often. If needed, we can discuss any issues with the medical doctor." S/he stated all the intake staff was trained to do MSEs (Medical Screening Exams), but that they always get confirmation from a physician to admit the patient, even with walk-in patients. S/he continued that all admission and intake processes are funneled through the intake department. S/he stated the physician could call the transferring facility if desired, but that was generally not done. The LIC was asked about bed availability. S/he stated, "That is done in our office. I can check that in 30 seconds. We have a bed board." When asked who accepts the patient, s/he stated, "The doctor will tell us if they are accepting the patient or not. We have a call tracking form that we write on for the patients denied." S/he confirmed that sample patient #20 had been accepted as the intake staff had signed the appropriate areas and placed the physician's name. The LIC was asked the process when the patient presents. S/he stated, "We verify the hold, Rights, and EMTALA form." The LIC was asked the process if there were not original forms. S/he stated, "Then we would not let EMS leave and would all the Administrator-on-call." The LIC confirmed there was a schedule for the physician on-call as well as the Administrator-on-call.

An interview was conducted with the Chief Medical Officer (CMO) on 11/6/12 at approximately 10:00 a.m. When asked if s/he was on-call that night, s/he stated, "I consider myself always on call," and confirmed that s/he had been that night. When asked about sample patient #20, s/he stated, "Without looking at the record, it was probably a case I reviewed with intake and accepted the patient." The CMO stated s/he was not informed that the patient was sent back to the transferring facility until the following day. The CMO was asked if the physician on-call is usually called upon patient arrival to obtain orders. S/he stated that if the intake person was a registered nurse, the orders could be given prior to arrival, but if the intake person was a social worker or psych person, they would get a call when the patient arrived to get physician orders. The CMO confirmed that s/he was not called the night of 10/24/12 - 10/25/12. The CMO was asked what would occur if the patient was not accepted. S/he stated s/he would inform intake staff of that decision and give one or two alternate assistive suggestions, such as the patient is too medically ill, etc. The CMO was asked if the facility could care for patients on oxygen. S/he stated, "We can do oxygen." The CMO confirmed that the usual process with admissions was for intake staff to call the physician over the phone. The CMO was asked how the on-call physician knew if there were available beds. S/he stated, "Actually, that is the question I ask. First I say it sounds appropriate, then the next question is 'do we have a bed?' I make an on the spot determination of where we can provide the needed services."

A telephone interview was conducted with the Director of Intake and Utilization Management on 11/6/12 at approximately 11:20 a.m. The Director was asked the expectation of when staff were on-call. S/he stated that ideally they would have staff on 24/7 and this was a rare instance, however, if the on-call staff needed to go in to the hospital, they would. When asked about the transfer process, s/he stated, "We review the packet before the patient comes in. They review prior to the patient acceptance and get the admit order from the psychiatrist." When asked where it would be documented that the patient was accepted for admission, s/he stated on the comprehensive assessment and on the tracking form, which both contained documentation for sample patient #20. The Director stated s/he was informed about the event the following day and took over facilitating the patient's admission thereafter. When asked about staffing in order to avoid an on-call situation in the future, s/he stated they always have someone scheduled 24/7, they were training a new staff member who could cover PRN, and that s/he usually can cover but was unavailable that one particular day.

An interview was conducted with the facility's Chief Clinical Officer on 11/6/12 at approximately 11:4 0 a.m. S/he confirmed s/he had not been called the night of 10/25/12 and that s/he learned of the situation in the morning. When asked about EMTALA training for nursing staff, s/he stated they were all trained upon initial hire, annually in their skills fair, and that Nursing Supervisors were involved in the intake process during their shifts. When asked about the incident, s/he stated they did not look at it as an EMTALA violation but rather as communication problems.

On 11/6/12 at approximately 12:20 p.m., an interview was conducted with the Licensed Professional Counselor (LPC) who conducted intake on the sample patient #20 on 10/24/12. S/he stated, "I took the initial call from the ER inquiring whether we could look at accepting [the patient]. I asked [the staff member at the transferring facility] to fax over the paperwork: psych eval, M1, and labs typically. I called back to get the M1. She had a lot of medical problems. I consulted with psych to see if [s/he] wanted anything else. I called up to the unit nurse to see if we could handle oxygen. I ran it by the doctor and [s/he] said it was fine, so we accepted the patient." The LPC was asked if there were available beds. S/he stated, "We have a board to see who is coming and leaving. I don't remember specifically, but I'm assuming there was availability or I wouldn't have had them send all the information: it would have been a moot point." The LPC confirmed that s/he spoke with the CMO at 10:30 p.m. that night and finished the assessment at 20 minutes after midnight. S/he confirmed that s/he left the facility before 1:00 a.m. When asked if the transferring facility had called prior to departing, s/he did not recall but stated, "I asked them if they wanted to transfer the patient in the middle of the night in a snowstorm and they didn't think it was any big deal." The LPC confirmed it was snowing in the mountains the night the patient's attempted transfer and admission occurred.