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Based on review of 19 closed and 2 open emergency department records including 10 closed behavioral health referrals, hospital #1 documentation, Medstar Franklin Square Hospital (MSFSH) Referral Checklist for Psychiatric Referrals; MSFSH Behavioral Health Referral Log, the Behavioral Health - Admission Criteria Policy (BHACP) (Effective 1/24/2019) and the Admission Referral-Updated Inpatient Unit Acuity for the behavioral health unit, along with staff interview, it was determined that for 10 attempted behavioral health referrals from outside hospitals, 4 were canceled for a lack of requested documentation and 6 were denied.

Some examples include: 1) The hospital referral checklist for behavioral admissions contains a list of 18 required elements that include several medical tests that may not be clinically indicated and may not be needed to admit and treat a behavioral health patient. The referral for patient #1 was canceled due to the lack of receipt of an electrocardiogram (EKG) that the sending hospital's physician said was not clinically indicated. 2) patient #9 was canceled due to the referral being conditioned on receiving a urinalysis for which no clinical indication was noted. 3) The "Admission Referral-Updated Inpatient Unit Acuity" form revealed disparities in accuracy related to unit acuity leading to denials of behavioral health patients #5 and #10.

1) Patient #1 (P1) was an adult who presented to hospital #1 (H1) in July 2019. P1 was clinically evaluated and determined to require inpatient treatment. P1 agreed to a voluntary admission and hospital #1 began the process of referral, seeking an inpatient behavioral health treatment bed.

A referral to MSFSH was made. MSFSH advised H1 to fax specific clinical information on their "Referral Checklist for Psychiatric Referrals" including a "REQUIRED" EKG (aka ECG or electrocardiogram which tests the electrical activity of the heart). However, the H1 physician declined to order an EKG based on the fact that P1's presentation revealed no indication that an EKG test was clinically needed.

Documentation in H1's referral record for P1 revealed at 2148 in part, "Writer contacted MSFSH to state that clinical was being faxed but that an EKG order has been declined. (MSFSH's referral contact #1) informed this writer that without an EKG the clinical [information] would not be sent to the unit for review. Writer informed (MSFSH's referral contact #1) that (physician at H1) was willing to have a doctor to doctor discussion to inform the reviewing physician why (physician at H1) will not order an EKG. (MSFSH's referral contact #1) suggested that the ED physician write a brief note explaining why an EKG will not be done."

According to documentation, P1 had an emergency condition requiring admission for behavioral health treatment, MSFSH conditioned P1's acceptance on an EKG which had been clinically determined by H1's physician as unnecessary. Further, even though H1's physician was willing to speak with MSFSH's reviewing physician, no effort was made to facilitate that discussion.

Documentation in H1's referral record revealed at 2153, "... (Physician at H1) remains willing to speak with MSFSH's reviewing physician so that clinician can justify the need for an EKG. At this time MSFSH maintained that clinical can be faxed for review in the morning. Clinical will be faxed for review in the morning."
Per MSFSH's referral form for P1, an untimed entry was made by (MSFSH referral contact #1) which stated, "No f/u (follow-up) referral canceled." On the behavioral health referral log, an entry of 0730 was placed which stated in part, "Cancel paperwork not received."

Review of ongoing referral documentation for H1 revealed in part at 0933, "Per MSFSH's referral contact #2, the referral was canceled last night due to the chart being incomplete (EKG). There is no longer a bed available on their unit at this time."

Following cancellation of the H1 referral, an "UPDATE" was placed into the H1 referral record which revealed in part that P1's insurance carrier communicated with MSFSH and the referral was re-opened. MSFSH referral contact #2 stated that "MSFSH behavioral health unit was starting to have some discharges." P1 was eventually admitted and in fact an EKG was completed and sent.

In summary, P1's admission had been conditioned on H1 performing clinical testing which was not necessary to treatment, and the MSFSH referral contact failed to facilitate a discussion which may have led to admission for P1. Finally, the referral was, without clinical input, canceled altogether by MSFSH, and would have remained so had P1's insurance carrier not intervened.

2) Patient #9 was an adult who presented to hospital #3 in June 2019 with multiple stressors. It was clinically determined that patient #9 needed inpatient behavioral health treatment, and P9 agree to a voluntary admission.

The behavioral health referral log for MSFSH revealed that P9's referral was canceled due to a urinalysis and nursing notes not being received. Review of the faxed clinical information revealed that in fact nursing notes were part of the package, and that no clinical condition indicating a need for a urinalysis was noted in the record. Included in the packet was a urine toxicology screen. Review of this referral revealed that like P1, the potential for clinical review was limited due to an arbitrary list of demands by MSFSH.

3) The MSFSH behavioral health unit has 29 beds including 5 private beds. Acuity for the behavioral health unit was determined through the Admission Referral-Updated Inpatient Unit Acuity (unit acuity) form. Acuity points on the form included such elements within a 12-hour period as the number of "psychotic Patients; Manic Patients, Patients on Behavior Modification, Self-injurious Patients; Active Seclusions; Active Restraints/Physical Assists; Number of Behavioral Health Emergency calls; Patients refusing medication, etc..." However, interview with the staff educator on 7/22/19 at approximately 1030 revealed in part that multiple numbers of restraint in 12 hours could be represented by just one patient. That patient would also fall under categories of agitation, and perhaps other categories. In this way, the unit acuity assessment could make the unit look exponentially and inaccurately, more acute.

Further, categories which combined elements such as "Active Restraints/Physical Assist" revealed two elements with disparate acuity levels, further skewing the accuracy of the unit acuity. Additionally, while the form made an attempt to define acuity, no weights were given to any element, so that the score of acuity which could range 1-5 remained arbitrary.

P5 was an adult patient who had a guardian. A referral was made to MSFSH for involuntary admission. The unit acuity form revealed an acuity of 4 and a census of 19 plus 1 coming admission and 8 available beds. P5 was denied due to the documented, "The pt has a guardian where mean (sic) (P5) has cognitive impairment which means (P5) would not meet admission criteria.

Review of P5's record identified that the guardian was a guardian of finances, and not of person. This meant that P5 was denied, without clinical input, based on an inaccurate understanding of P5's status.

P10 was an adult patient who was referred for involuntary admission. The unit acuity assessment at the time of referral revealed an acuity of 4.5 with a census of 18 plus one coming admission with a bed availability of 8, no restraints, no seclusions, and no 1:1 observations. Documentation on the acuity form revealed multiple entries, many illegible, detailing why the unit was too acute to admit P10. However, the acuity form did not otherwise support an acuity finding of 4.5 where such ratings remained subjective and arbitrary.