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COMPASS SENIOR CARE HOSPITAL 1 HOSPITAL DRIVE, SUITE 201 JENNINGS, LA 70546 July 26, 2016
VIOLATION: OFF-CAMPUS EMERGENCY POLICIES AND PROCEDURES Tag No: A0094
Based on record review and staff interview the Governing Body failed to ensure the Medical Staff had written policies and procedure to address situations in which a person's emergency needs may exceed the capabilities of the off-campus department as evidenced by the hospital policy relying on 9-1-1 for its emergency response capabilties. Findings:

Review of the Outpatient Policy titled, Suicidal/Homicidal/Gravely Disabled Patient, Policy #OP-311, revised July 2016, provided by SF3PD as the plan of correction for PHP deficiencies cited during the previous survey dated 06/16/16 revealed the following:
When a partial hospitalization or intensive outpatient patient is identified, through clinical assessment, as being suicidal, homicidal, and/or gravely disabled and requiring inpatient hospitalization , the following procedure must be followed:
1. A staff member must remain with the patient at all times.
2. The patient is to be immediately placed on one-to-one observation with a staff member. The patient must not leave the program alone.
3. The attending physician is notified of the patient's status and necessary orders are obtained.
4. If the patient is unwilling to seek voluntary admission to inpatient treatment, staff is to contact 9-1-1 for emergency assistance or accompany the patient to the nearest emergency room .
5. The patient's information is sent to the Intake Department so that transfer of the patient to an inpatient unit can be arranged according to intake processes and procedures....

Further review of the policy revealed no provision that if an outpatient at the offsite campus required inpatient hospitalization , the offsite campus would be required to send the patient to the main campus if the main campus had beds available. Review of the policy revealed no provisions for apprasials of patients with emergencies.

In an interview on 07/26/16 at 9:00 a.m., SF3PD stated the corporate entity has a central intake for all their facilities when a psychiatric inpatient bed is needed in a non-crisis situation. SF3PD stated if a physician was onsite in the PHP when a patient decompensates, that physician can PEC the patient, and then the patient could go to the main campus hospital. SF3PD stated if a physician is not onsite in the PHP, then the patient (decompensated in a crisis situation) would go to the emergency room at the closest hospital. SF3PD stated the main campus was 45 minutes away from the PHP. SF3PD stated the closest hospital was Hospital "FC". She stated SF7Physician requests his patients go to Hospital "FB."

In an interview on 07/26/16 at 1:45 p.m., SF1ADM confirmed the above policy was the only policy the hospital had for transfer of PHP patients who experience psychiatric decompensation. He confirmed the policy did not include a provision that the offsite campus was required to send the patient to the main campus. SF1ADM stated it was difficult getting patients transferred across parish lines and the ambulance staff want to take the patient to the nearest facility. SF1ADM stated if they could get the patient to the main campus, they have physicians available to see the patient and PEC the patient if needed. SF1ADM confirmed the procedure for transfer of decompensated patients in crisis from the PHP was to call 9-1-1 and transfer to the emergency room .