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.

SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM 6262 SOUTH SHERIDAN ROAD TULSA, OK April 22, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on document review and staff interview, it was determined the hospital failed to:

a. maintain records of patients who were transferred to or from the hospital. See tag A-2403;

b. maintain an accurate and complete emergency room log that reflected the patient's chief complaint, emergency status, patient disposition, and time of discharge. See tag A-2405; and

c. the hospital failed to accept an appropriate transfer of individuals with emergency medical conditions when the hospital had the capability and capacity to accept a transfer and failed to prohibit the delay in treatment to inquire about payment status. See tag A-2411.

The hospital did not include compliance with EMTALA requirements as a part of it's quality assessment and performance improvement program.
VIOLATION: HOSPITAL MUST MAINTAIN RECORDS Tag No: A2403
Based on document review and staff interview, it was determined the hospital failed to maintain records of patients who were transferred to or from the hospital.

On 04/21/2016, the hospital CEO was asked to provide records for those patients who were transferred to or from the hospital for the past five years. The CEO stated the hospital did not keep track of those patients and he could not produce those records.

The hospital did not have a policy that required patient transfer records to be maintained for a period of five years.

The hospital did not include compliance with EMTALA requirements as a part of it's quality assessment and performance improvement program.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on document review and staff interview, it was determined the hospital failed to maintain a central log that was complete and accurate.

Findings:

1. The hospital's EMTALA log did not accurately reflect the patient's chief complaint when they presented to the emergency department. The log documented "behavior disorder" for nearly every patient who presented to the emergency department, regardless of age, presenting symptoms or patient complaint.

The hospital's emergency log policy documented the staff were required to record the "nature of the presenting complaint." When asked why the hospital documented the same complaint for nearly every patient, the Director of Admissions and the CEO had no response.

2. The EMTALA log for April 01 through April 21, 2016 documented that none of the patients who presented to the hospital were emergency patients, although 125 of these patients were directly admitted to the hospital. A few entries in the log documented patients had attempted suicide or had suicidal ideation. These were not classified by the hospital as an emergency medical condition.

The hospital's emergency log policy required staff to document "whether or not the individual presenting has an emergency medical condition as defined by hospital policy..." A policy titled, "Emergency Screen and Patient Transfer" documented, "... An emergency medical condition is defined as:
A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in... placing the health of the individual... in serious jeopardy... serious impairment of bodily functions... serious dysfunction of any bodily organ or part..."

3. The hospital EMTALA log for April 01 through April 21, 2016 had 11 gaps in disposition information for patients who presented to the hospital emergency department. There were 30 gaps in the documentation of departure times from the hospital emergency department. Some of the logs provided during the survey had no date documented on them.

A hospital policy, titled "Emergency Log," required staff to document patient disposition and departure times of all patients who presented to the emergency department.

4. The hospital CEO and the Director of Admissions verified the EMTALA log was not always complete or accurate. They were asked who was responsible for completing the EMTALA log. They stated the reception staff were responsible for this task. This was in conflict with the hospital's emergency log policy that required the admissions staff to enter data on the EMTALA log

The Director of Admissions was asked for the EMTALA training materials provided to the reception staff. A "Reception Orientation Booklet" was provided. The only EMTALA training included in this booklet was documented as "EMTALA Log." The instructions documented,

"Receptionists are responsible for documenting each individual that arrives for an assessment into the EMTALA log. If you are replacing someone at the desk, you should ask if the log is up to date. If you are not replacing someone, you need to ask admissions and 1 west if there were any walk-in assessments that occurred overnight so you can add them to the appropriate log page. Please check the log from the previous day and ensure it is complete and correct if there is information missing."

There was no documentation the receptionists were trained to identify and document a chief complaint, identify and document an emergency medical condition, to identify and document the patient disposition and to include all discharge times on the log. There was no instruction in the orientation booklet that instructed the reception staff on where to get this information.

The Director of Admissions stated the reception staff were supposed to "fill in the log" with information from any emergency room admissions that occurred after hours when a receptionist was not on duty. She stated that usually the nursing staff left the information for the receptionists to add to the EMTALA log. The hospital had no documentation the nursing staff were instructed on the documentation requirements for the EMTALA log.

The hospital's emergency log policy required the following, "... The Admissions Director or qualified designee will review each completed Emergency Log form for accuracy and completeness. Upon review, the Director of designee will sign and date each log..."

The EMTALA log had no documentation it was reviewed by the Admissions Director or a designee.

The EMTALA log was not included in the hospital's quality assessment and performance improvement program.
VIOLATION: RECIPIENT HOSPITAL RESPONSIBILITIES Tag No: A2411
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interview, the hospital failed to accept appropriate transfers from referring hospitals when it had the capability and capacity to do so, and the hospital delayed treatment to inquire about payment status.

Findings:

On 04/09/2016, hospital B assessed a [AGE] year old male patient (#64) with an emergency medical condition. The patient was having suicidal and homicidal ideation with command-type auditory hallucinations. At the time, hospital B documented it did not have the capacity to admit an adult male patient.

On 04/21/2016, hospital B stated they attempted to transfer patient #64 to Hospital S and were denied a transfer. Hospital B did not provide documentation of why Hospital S denied the transfer. The patient was ultimately transferred to another hospital out of town.

The hospital was asked to provide documentation of patients who were accepted for transfer and those who were refused transfer from a referring hospital. The CEO stated the hospital did not track this information.

The Director of Admissions was asked how the hospital documented calls that came into Hospital S regarding requests for transfers from other hospitals. She stated the hospital had a phone log of all inquiry phone calls.

The hospital's phone log documented hospital B contacted Hospital S on 04/09/2016 at 11:47 a.m. regarding a transfer for patient #64. The phone log documented the patient's disposition as "chose another facility."

A review of the phone log for March 31 through April 21, 2016 documented Hospital S was contacted by referring hospitals multiple times during this period. The log documented 38 of 38 patients without a payment source were denied a transfer or were not admitted for inpatient care. The log also documented 40 of 41 patients with a payment source were accepted for transfer from another hospital and were admitted . One patient with a payment source that was not accepted by the hospital was denied admission.

As an example, on April 19, 2016 the phone log documented Hospital S denied referring hospital transfers for seven of seven patients with no documentation of a payment source and accepted three of three patients with a payment source.

The phone log documented transferring patients were assessed by Hospital S but the log did not specify whether transferring patients were assessed in person or if the assessments were conducted over the phone. The Director of Admissions stated the hospital on-call physician sometimes made decisions over the phone about whether or not to accept a transfer from a referring hospital.

The person conducting the assessment was not always documented on the phone log. The log documented the following reasons for refusing a transfer from a referring hospital ED:

04/02/16 patient #50 referred back to [outpatient] provider by physician B.
04/04/16 patient #52 referred to [outpatient] by physician B.
04/04/16 patient #55 "denied by" physician C. No detail given.
04/05/16 patient #56 refused transfer. Referred to a community mental health clinic.
04/05/16 patient #58 "no Medicare days left."
04/09/16 patient #63 "denied for acute care" by physician D.
04/10/16 patient #68 "denied for admission" by physician D.
04/11/16 patient #71 "not appropriate for inpatient" by physician A.
04/12/16 patient #72 "refused transfer" by physician E
04/13/16 patient #73 "physician E states they [referring hospital] have the capacity to treat."
04/14/16 patient #76 " Per doctor A refer to [other hospital]."
04/15/16 patient #77 no disposition documented
04/19/16 patient #77 "not appropriate for acute, can refer to possible ASD list"
04/19/16 patient #81 "referred to outpatient by physician E"
04/19/16 patient #82 "referred to outpatient by physician E"

Only twice, once on 04/11/2016 and once on 04/19/2016, the hospital documented there were no beds available for a transfer request from a referring hospital.

The phone log was missing disposition information for ten requests for transfer during April 2016.

During this time period, the phone log documented ten occasions when patients went to other hospitals after a request for transfer to Hospital S was made by a referring hospital. All of these patients had no documentation of a payment source.

The phone log also documented Hospital S delayed a decision about an acceptance or a denial of a transfer request by hours or even until the next day. On some occassions, patients were transferred to other hospitals while they waited for a response from Hospital S.