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.

CAMBRIDGE HOSPITAL LLC 7601 FANNIN HOUSTON, TX April 7, 2015
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
Based on record review and interview the facility failed to have written on-call procedures in place to ensure the availability of a psychiatrist to provide treatment for patients coming through their intake unit. Citing one (1) patient named in a complaint, Patient #1.

Findings:
During an interview on 4/6/2015 at 2:12 pm at the facility with the Director of Nursing (DON), she gave the following information:
The facility did not have an on-call roster or on-call policy for the psychiatrists. She stated there were three (3) psychiatrists that see patients in the facility and when there is an admission, the facility will call whoever is available to take the call.
According to the DON, if there is a walk-in patient, the patient would be screened by the Telemedicine physician and admitted as needed. Psychiatric care would start when there is an available psychiatrist.
The DON stated there were occasions when the facility have beds but could not accept patients because there was no available psychiatrist. Some psychiatrists will tell facility staff they were not accepting patients. As a result, staff would not call that psychiatrist if there is an admission. She stated the psychiatrist does not necessarily say why he or she will not accept a particular patient for care.

During an interview on 4/7/2015 at 1:15 pm with Intake Staff Mr. K, he stated some psychiatrists will not accept new admissions . He stated psychiatrists are allowed to see a set number of Medicare patients each month and cannot accept anymore patients once they reach that limit. Mr. K stated the psychiatrists see patients at other facilities and are sometimes overwhelmed. He stated there was no on-call system, staff call around until one of the three psychiatrists take the patient or not.

During an interview on 4/7/2015 at 11:10 am with the Interim Administrator, he stated he was not aware an on-call system was required for the psychiatrists. He stated a system would be implemented.

During an interview on 4/6/2015 at 9:15 am with the Chief Executive Officer, he stated that in mid-January 2015, the facility had a re-boot and in the past 30 days there has been an active re-hiring process.

Review of the facility's EMTALA Policy/Procedure dated 3/31/2015 gave the following information as purpose:
"To identify guidelines for providing the appropriate setting (department) for conducting medical screening.
To identify requirements for emergency medical screening.
To identify providers eligible to perform the emergency medical screening.
To comply with Emergency Medical Treatment & Active Labor Act (EMTALA), 42 U.S.C. section 1395 and subsequent federal interpretive guidelines and state regulations."
The policy did not address on-call psychiatrist coverage at the hospital in the event there is an emergency transfer or admission of a psychiatric patient.

Review of the facility's Medical Staff Bylaws Rules and Regulations, signed and dated 12/8/2014, revealed the document contained a paragraph at 14.1 titled Rules and Regulations. There was no mention of EMTALA requirements or psychiatrist responsibilities as it relates to EMTALA in the document. There was no on-call requirement for the psychiatrists.

Review of credential files for the three (3) psychiatrists providing patient care at the facility revealed two of the psychiatrists were granted privileges to see patients eighteen (18) years and older. One psychiatrist, who is also the Medical Director, had privileges to see patients from age four (4) and older. There were no on-call responsibilities on their privileges in the facility.
There was no information on the credential files that the psychiatrists were given EMTALA training.
VIOLATION: RECIPIENT HOSPITAL RESPONSIBILITIES Tag No: A2411
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to accept a patient that required psychiatric treatment from a referring hospital that had no psychiatric capabilities. This failed practice resulted in the patient staying several days in the emergency room of the acute care facility. Citing one (1) patient named in a complaint, Patient #1.

Findings:
Review of emergency room (ER) record for Patient #1 revealed the following information:
Patient #1, [AGE] years old, arrived at Hospital QY on 3/11/2015 at 15:43 accompanied by law enforcement with an Emergency Apprehension and Detention Warrant. He was apprehended at home by Police because of agitation and need for mental health evaluation.
There was information Patient #1 was recently released from prison reportedly for murder.
Review of History and physical revealed documentation the patient's primary symptoms was: hallucinations and bizarre behavior. No homicidal or suicidal ideas. He was talking to people that were not there.
On arrival to the (ER) his initial vital signs were: blood pressure 162/94, heart rate 91, temperature 98.5 and respiration 18. He weighed 137 pounds and oxygen saturation was 92%. All other physical assessment was within normal limits. There was documentation the patient confabulates and responds inappropriately.
The patient was examined by the physician and was diagnosed with paranoid psychosis.
His presenting problems were documented as "high".
Diagnostic procedure "high" and management options "high".
Review of diagnostic tests dated 3/11/2015, revealed during his stay in the emergency room , Patient #1 had a CT of brain which was unremarkable. His blood and urine were also analyzed.

Review of Social Worker notes dated 3/13/2015, revealed information that during an interview with the patient, he stated he hears voices at times that tell him to do things. He stated he did not do the things the voices told him to do.
The notes documented the patient talked continuously stating he had a doctorate degree in everything. The patient denied drug or alcohol use. His affect appears calm during the interview. The patient's thought process appears tangential. He appears to be responding to internal stimuli and appears to present with psychosis.

Medication Administration Record revealed Patient #1 received intramuscular Ativan and Geodon (anti psychotic medication). He also was given oral Geodon .

Review of physician's notes dated 3/16/2015 at 14:44 revealed the following documentation:
"While the patient is psychotic he is no threat to himself or others and has been quite cooperative in a busy ED for several days awaiting placement. The family is willing to take him home, and he will be discharged ."

Review of nurses' notes dated 3/11/2015 - 3/16/2015 revealed the facility staff made multiple attempts to place Patient #1 in a psychiatric facility with no success.

Review of intake information at Hospital NJ on 4/6/2015 - 4/7/2015 revealed the following information:
Admission/MOT Log dated 3/13/2015 documented the facility had three (3) admissions for that date. Two (2) of the admissions were referrals from a hospital and the third was a re-admission. All three (3) patients had health insurance and were accepted by two different psychiatrists.
The referral from Hospital QY for Patient #1 was not on the log.

There was information in the intake unit that a request for services was made from Hospital QY for Patient #1 which included a copy of the faxed medical record and Hospital NJ Exclusionary Criteria information that was completed by Hospital QY. Attached to the patient information was an insurance verification sheet with information the patient was "self-pay".

Hospital NJ staff told the Surveyor the insurance verification was done at their hospital. There was no information on the intake record indicating the status of the request for care.

Review of the facility's in-house census for 3/13/2015 revealed the total number of patients was twenty-seven (27). The facility had the capacity for forty (40) patients.

During a telephone interview on 4/6/2015 at 8:30 am with Mr. G, he stated he is the Manager of Continuum of Care at Hospital QY. Mr. G stated on 3/13/2015, Patient #1 had been in the emergency room for two days displaying psychotic behavior. The patient needed care in a Psychiatric Hospital and Hospital QY did not have the capability to treat the patient. He stated the patient had no resources and was waiting for placement at a public psychiatric hospital.
Mr. G stated since the patient was in the ER waiting for placement for two days, he decided to call some of the private psychiatric hospitals.
He contact the Hospital NJ in Houston and was informed by their intake unit that there were available beds. Mr. G said he faxed over the intake information but when he called back to get the status of his referral, he was informed by the Intake personnel, Mr. K, that the facility had beds but a self-pay patient must put money up front before they could accept the patient.
Mr. G stated he told Mr. K that the patient is in the ER and the hospital did not have the capability to treat the psychiatric patient. Mr. K responded by saying since the patient was in the emergency room (ER), all the hospital had to do is keep him there and stabilize him. According to Mr. G, he told Mr. K that refusing the patient because of money was an EMTALA violation and Mr. K told him EMTALA requires Hospital QY to stabilize the patient because he was already in their emergency room .
Mr. G stated Patient #1 spent five (5) days in the ER because he could not get Psych placement.

During an interview on 4/7/2015 at 1:15 pm with Mr. K, Licensed Social Worker, he stated he had been working in the facility since 2014 and was assigned as an Intake Coordinator since March 2015.
According to Mr. K, a staff member from Hospital QY called inquiring about a referral that was made earlier on. Mr. K stated he asked the facility staff why he was referring the patient to Hospital NJ when there were closer hospitals to their hospital that the patient could be sent.
Mr. K stated the facility had beds, but he did not think the patient should be transferred a hundred (100) miles to Hospital NJ when he was already in the emergency room at Hospital QY. Mr. K told the Surveyor it was his opinion that Hospital QY should keep the patient, stabilize him, and then send him home.
When questioned about the allegations that he requested the patient pay up front because he did not have insurance, Mr. K stated he did not ask about insurance, it was reported to him that the patient was self-pay and he might have told the staff at Hospital QY that upfront payment is required for self-pay patients.
Mr. K informed the Surveyor that it is the hospital's procedure to verify the insurance of all patients calling for service. If the patient is self-pay, then upfront payment is required.
Mr. K stated he made the decision not to take the patient because he felt there were closer hospitals he could be sent.

During an interview on 4/6/2015 at 8:50 am with the Chief Executive Officer, he stated that Hospital NJ had a bed capacity of 148 but is currently staffed for 40.

Review of the facility's EMTALA Policy/Procedures dated 3/31/2015 gave the following information as purpose:
"To identify guidelines for providing the appropriate setting (department) for conducting medical screening.
To identify requirements for emergency medical screening.
To identify providers eligible to perform the emergency medical screening.
To comply with Emergency Medical Treatment & Active Labor Act (EMTALA), 42 U.S.C. section 1395 and subsequent federal interpretive guidelines and state regulations."
The policy did not address the Hospital's recipient responsibilities to other Medicare participating hospitals.

Review of the facility's Medical Staff Bylaws Rules and Regulations, signed and dated 12/8/2014, revealed the document contained a paragraph at 14.1 titled Rules and Regulations. There was no mention of EMTALA requirements or physician responsibilities as it relates to EMTALA in the document.