HospitalInspections.org

Based on record review and interview the hospital continues to fail to comply with 489.24 by failing to ensure the hospital accepted the transfer of patients in need of the specialized psychiatric services offered by the hospital when the hospital had the capability and capacity to accept the transfer for 5 of 35 patients reviewed for processing transfer request of patients with psychiatric emergency medical conditions (#R8, #R17, #R27, #R34, #R37) (See findings cited at A2411).

Based on record review and interview the hospital failed to ensure it accepted the transfer of patients in need of the specialized psychiatric services offered by the hospital when the hospital had the capability and capacity to accept the transfer for 5 of 35 patients reviewed for processing transfer request of patients with psychiatric emergency medical conditions (#R8, #R17, #R27, #R34, #R37). Findings:

A review of transfer request was conducted for the dates of 4/01/2010, 4/02/2010, 4/04/2010, and 4/12/2010.

4/01/2010
The hospital's Daily Census and Inquiry Request Log were reviewed. Six transfer requests were found for the date of 4/01/2010. Two patients were accepted. Four patients denied. The midnight census dated 4/01/2010 revealed the hospital census to be 9 patients on the Geriatric Unit out of a total of 12 beds (3 available) and 7 patients on the adult unit out of a total of 16 beds (9 beds available).

Patient #R8 (25 year old male):
Review of Patient #R8's Focus Behavioral Inquiry Call Form dated 4/01/2010 at 3:46 a.m., revealed "Brief History of problem: Voices telling him to kill somebody and do crazy things. Involved in altercation w (with) laceration to r (right) hand." Further review revealed no documented evidence of who completed the form and no documented evidence that the information was reviewed with any physician on staff at Focus Behavioral Hospital. This finding was confirmed by Administrator S1 and Admission Coordinator S13.

Review of faxed information from Hospital A revealed #R8 was committed with a Physician's Emergency Certificate on 3/31/2010 at 0737 (7:37 a.m.) due to requesting help for voices telling him to "kill somebody and do crazy things." PEC review further revealed the patient (#R8) had mild swelling of his lip and a scratch to his right hand. Lab review (Hospital A) revealed #R8's alcohol level to be 54.4 on 3/31/2010 at 2240 (10:40 p.m.). Further review revealed, "The above result is obtained on either a serum or plasma specimen as opposed to whole blood. An approximation of the whole blood percentage of alcohol can be obtained by dividing the value in mg/dl (milligrams per deciliter) by 1,000 (e.g. 50 mg/dl = 0.05 %)."

The Hospital's Daily Census and Inquiry Call Log were reviewed with Administrator S1 and Admission Coordinator S13 on 4/16/2010 at 9:20 a.m. S1 indicated she could see no reason that Patient #R8 could not have been admitted to the hospital because #R8 met admission criteria as per her review of the Inquiry Call Form and Hospital A's Emergency Department Fax. S1 further indicated, after review of the Hospital's Midnight Census, that the hospital also had a bed available for placement on the Adult Unit. S1 indicated there was no documented evidence as to who had taken the call and she could find no reason to deny the transfer request.

4/02/2010
The hospital's Daily Census and Inquiry Request Log were reviewed. Seven transfer requests were found for the date of 4/02/2010. Two patients were accepted. Five patients were denied. The midnight census dated 4/02/2010 revealed the hospital census to be 9 patients on the Geriatric Unit out of a total of 12 beds (3 available) and 7 patients on the adult unit out of a total of 16 beds (9 beds available).

Patient #R17 (56 year old female):
Review of Focus Behavior Hospital's Inquiry Call Form for Patient #R17 dated 4/02/2010 at 0924 (9:24 a.m.) revealed a "Brief History of the problem" to be documented as "(increased) suicidal thoughts and anxiety; plan to OD (overdose)." Review revealed the final disposition of the referral as "no beds". Further review revealed no documented evidence of who completed the form and no documented evidence that the information was reviewed with any physician on staff at Focus Behavioral Hospital. This finding was confirmed by Administrator S1 and Admission Coordinator S13.

Review of Hospital B's Emergency Department faxed referral information for Patient #R17 revealed the patient was committed with a Physician's Emergency Certificate on 4/01/2010 at 1530 (3:30 p.m.) for reporting increase in suicidal thoughts with depression and anxiety with plan to overdose (positive attempt in past). Further record review revealed #R17 had been hearing voices telling her to kill herself.

The Hospital's Daily Census and Inquiry Call Log were reviewed with Administrator S1 and Admission Coordinator S13 on 4/16/2010 at 9:20 a.m. S1 indicated she could see no reason that Patient #R17 could not have been admitted to the hospital because #R17 met admission criteria as per her review of the Inquiry Call Form and Hospital A's Emergency Department Fax. S1 further indicated, after review of the Hospital's Midnight Census, that the hospital also had a bed available for placement on the Geriatric Unit. S1 indicated there was no documented evidence as to who had taken the call and she could find no reason to deny the transfer request.

4/04/2010
The hospital's Daily Census and Inquiry Request Log were reviewed. Five transfer requests were found for the date of 4/04/2010. Two patients were accepted. Three patients were denied. The midnight census dated 4/04/2010 revealed the hospital census to be 11 patients on the Geriatric Unit out of a total of 12 beds (1 bed available) and 9 patients on the adult unit out of a total of 16 beds (7 beds available).

Patient #R27 (28 year old male): 7 beds available as per the midnight census on 4/04/2010.
Review of Focus Behavioral Hospital's Inquiry Call Form for Patient #R27 dated 4/04/2010 at 1641 (4:41 p.m.) revealed the "Brief history of the problem" to be "Psychosis, paranoid, pt. (patient) seeing things that are not there, confused". The final disposition for the transfer request was documented as "no beds" . Review revealed no documented evidence of who completed the form and no documented evidence that the transfer request was ever reviewed with a physician on staff at Focus Behavioral Hospital.

Review of the faxed Hospital C Emergency Department record for Patient #R27 revealed the patient was committed by a Physician's Emergency Certificate on 4/03/2010 at 1434 (2:34 p.m.) for paranoia, visual hallucinations: "acute psychosis and paranoia especially while driving. Pt (patient) sees the road but knows it isn ' t there and he gets really confused especially with heavy traffic. Pt has strong urge to hit his head against walls and punch things." Further review revealed #R27's drug screen and alcohol level to be negative.

The Hospital's Daily Census and Inquiry Call Log were reviewed with Administrator S1 and Admission Coordinator S13 on 4/16/2010 at 9:20 a.m. S1 indicated she could see no reason that Patient #R27 would not have been admitted to the hospital because #R27 met admission criteria as per her review of the Inquiry Call Form and Hospital A's Emergency Department Fax. S1 further indicated, after review of the Hospital's Midnight Census, that the hospital also had a bed available for placement on the Adult Unit. S1 indicated there was no documented evidence as to who had taken the call and she could find no reason to deny the transfer request.

4/12/2010
The hospital's Daily Census and Inquiry Request Log were reviewed. Nine transfer requests were found for the date of 4/12/2010. Two patients were accepted. Seven patients were denied. The midnight census dated 4/12/2010 revealed the hospital census to be 9 patients on the Geriatric Unit out of a total of 12 beds (3 beds available) and 11 patients on the adult unit out of a total of 16 beds (5 beds available).

Patient #R34 (46 year old female):
Review of Focus Behavioral Hospital's Inquiry Call Form dated 4/12/2010 at 0450 (4:50 a.m.) for patient #R34 revealed the "Brief history of problem" to be documented as "depression, bipolar, schizophrenia, OD (overdose) husband took away pills" with the final disposition of the transfer request to be "no female beds" . Further review revealed no documented evidence of reviewing the transfer request with any Focus Behavioral staff physician.

Review of Hospital D's faxed Emergency Department record for Patient #R34 revealed the patient was committed with a Physician ' s Emergency Certificated dated 4/11/2010 at 2100 (9:00 p.m.) for "suicidal ideation, husband had to take meds from her b/c (because) she wanted to OD (overdose). . . depressed. . . lots of stress. . . past overdose. . . (positive) S/I suicidal ideation. (positive) Homicidal although no one in mind. . ." Toxicology: negative drugs and alcohol.

The Hospital's Daily Census and Inquiry Call Log were reviewed with Administrator S1 and Admission Coordinator S13 on 4/16/2010 at 9:20 a.m. S1 indicated she could see no reason that Patient #R34 would not have been admitted to the hospital because #R34 met admission criteria as per her review of the Inquiry Call Form and Hospital A's Emergency Department Fax. S1 further indicated, after review of the Hospital's Midnight Census, that the hospital also had a female bed available for placement on the Adult Unit. S1 indicated there was no documented evidence as to who had taken the call and she could find no reason to deny the transfer request.

Patient #R37 (37 year old male):
Review of Focus Behavioral Hospital's Inquiry Call form for Patient #R37 as documented by Admission Coordinator S13 dated 4/12/2010 at 1254 (12:54 p.m.) revealed the "Brief history of problem" to be "bipolar, hearing voices, suicidal ideation." Further review revealed the final disposition of the transfer request to be "no beds" . Review revealed no documented evidence that the transfer request was ever reviewed with any Focus Behavioral staff physician.

Review of Hospital E's Emergency Department Record for Patient #R37 revealed the patient was committed with a Coroner's Emergency Certificate dated 4/12/2010 at 1229 (12:20 p.m.) for command hallucinations telling him to harm himself: bipolar disorder. Toxicology results revealed negative for alcohol and positive for benzodiazepines. Review of #R37's prescribed medications revealed the patient's medications included Xanax 0.25 milligrams by mouth three times per day.

The Hospital's Daily Census and Inquiry Call Log were reviewed with Administrator S1 and Admission Coordinator S13 on 4/16/2010 at 9:20 a.m. S1 indicated she could see no reason that Patient #R37 would not have been admitted to the hospital because #R37 met admission criteria as per her review of the Inquiry Call Form and Hospital A ' s Emergency Department Fax. S1 further indicated, after review of the Hospital's Midnight Census, that the hospital also had a bed available for placement on the Adult Unit. S1 indicated she could find no reason to deny the transfer request for Patient #R37.

During a face to face interview on 4/16/2010 at 10:35 a.m., Medical Director S21 indicated after verbally reviewing the Inquiry Calls for Patients #R8, R17, R27, R34, and R37 with the surveyor that it sounded like the patients should have been admitted to the hospital. Medical Director S21 indicated he had no recall of speaking with nursing staff about these patients (#R8, #R17, #R27, #R34, #R37).

During a face to face interview on 4/14/2010 at 10:30 a.m., Admission Coordinator S13 indicated she was the person that completed Inquiry Call Forms for transfer requests from other facilities. S13 indicated she worked Monday through Friday, day shift, and would be the person responsible for taking information from hospitals calling to seek bed placement while on duty. S13 further indicated she would also fill out inquiry forms when she arrived to work each morning based on faxes received overnight. S13 indicated she would not know who had taken the phone calls or what had transpired. S13 indicated she would use faxed information from requesting hospitals to complete the form and would document "no bed" for the disposition on all transfer requests that had not been admitted to the hospital in her absence. S13 indicated she would have no way of knowing who had taken the phone calls and what had transpired between the staff answering the phone or receiving faxes and the calling facility.

Review of Admission Coordinator S13's personnel file revealed no documented evidence of a competency evaluation to include no evaluation of processing Inquiry Calls for the hospital. This finding was confirmed by Hospital Administrator S1.

Review of the Job Description for "Admissions Assessment Coordinator" presented by the hospital as the current job description revealed in part, "Works with referral sources to evaluate patient needs and the services offered by the Focus Behavioral Hospital. Coordinates routine and emergency referrals and transfers. Screens patients for appropriateness and obtains admission orders from attending physician. Completes necessary admission paperwork.

Review of the hospital policy titled, "Transfer of Emergency Cases from other Hospitals" presented by the hospital as their current policy revealed in part, "Refusal of Transfer: If the individual proposed to be transferred does not have an unstabilized emergency medical condition, if Focus Behavioral Hospital does not have the specialized capabilities or facilities required by the individual proposed to be transferred, if the transfer is not an appropriate transfer, or if Focus Behavioral Hospital does not have the capacity to accommodate treatment of the individual, the proposed transfer must be refused, and Focus Behavioral Hospital's ordinary policies governing transfers and admissions shall apply under such circumstances. . . When receiving a call relating to a proposed transfer from a referring hospital of an individual with an emergency medical condition, the following procedures apply: Receives the call. . . Should notify the physician on-call and the administrator on call. The Admission Counselor should respond back to the referring hospital within approximately 30 minutes of the initial request, unless extended by the physician on-call. If questions arise as to whether Focus Behavioral Hospital has specialized capabilities or facilities required by individual, whether Focus Behavioral Hospital has the capacity to treat the individual whether the proposed transfer is an appropriate transfer, or whether the individual has an unstabilized emergency medical condition, the Admissions Professional should arrange for the physician on-call to discuss the proposed transfer with the referring physician (or other qualified medical personnel). All decisions regarding the existence of an unstabilized emergency medical condition, the existence of an appropriate transfer, the necessity of specialized capabilities or facilities, and the capacity of Focus Behavior Hospital to accept the individual shall be made by the physician on call. Will notify the referring facility of the decision to accept or refuse the transfer."


Review of the Hospital's Admission Criteria, presented as the current criteria, revealed in part, "For Adult unit: individual is between 18 and 49 years of age. For Geri-psychiatric unit: individual is at least 50 years of age or older. If 50 years old to age 54 can be placed on Geri unit as long as the patient is not violent or assaultive to others. Must have #3 and three or more of criteria #4 through #11: 3. Has current psychiatric illness which is primary. 4. Is suicidal/homicidal/ violent, psychotic or has the potential for suicidal/homicidal/violent behavior. 5. Is gravely disabled due to psychiatric symptoms and requires 24 hour supervision. 6) Is in danger of physical and psychological withdrawal complications. 7. Patient is unwilling or unable to comply with psychotropic medications and/or has a history of decomposition due to medication non-compliance. 8. Has experience deterioration of baseline psychiatric functioning and requires a more intensive level of care. 9. Cognitive Impairment requires daily medical/psychiatric assessment and management. 10. There is reasonable expectation that patient will benefit from and participate to the best of his/her ability in therapies and treatment planning regime. Treatment at a less intensive level of care has failed. Exclusionary Criteria: If any of the criteria numbered 12 through 23 are checked, individual is not appropriate for admission unless both the Medical Director and the Director of Nursing concur. 12. Medical condition that prevents full participation in psychiatric program (e.g. bedfast, global aphasia, etc) 13. Overdose: Patient is less than 24 hours post OD (overdose) or whose lab values are not normalizing. 14. Diabetes w (with)/sugar > (greater than) 400 within the last 24 hours (If >200 in ER (Emergency Room), must discuss with Psychiatrist before transfer). 15. ETOH (alcohol) levels over 200 mg/dl on presentation to ER or S/S (signs and symptoms) of active or impending Delirium Tremens. 17. Requiring Drug or Alcohol Detox only, without primary diagnosis of Psychiatric Illness. 18. Serious cardiovascular symptoms: Chest Pain, Labile, or Uncontrolled HTN (hypertension); any S/S consistent with MI (Myocardial Infarction) or CVA (Cerebral Vascular Accident) (until fully examined and ruled out or successfully treated). 19. Complex Hypertension - patients not stabilized to a Systolic less than 200 and a Diastolic under 110 maintained over at least a 24 hours period after active treatment has been initiated. 20. Delirium secondary to known medical condition or cause (including substance abuse). 20. Central IV (Intravenous) Lines, IV Chemotherapy, Hyperalimentation, PCA (Pain Control Administration), or other IV infused narcotics, Continuous IV treatment. 22. Conditions requiring Dialysis, 23. High fever (greater than or equal to) 103 and not responding to treatment."