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Based upon reviews of hospital policies/procedures, Intake Referral Forms, Referral logs, Inpatient census reports, and interviews, the hospital failed to meet the EMTALA requirements as defined in CFR 489.24 for failing to provide inpatient psychiatric treatment for 1 of 21 patient referrals reviewed (#1) and one unidentified psychiatric patient referral, who required hospital admission, when the hospital had the capability and capacity to provide the necessary treatment. (A2411)

Based upon review of admissions department referral log, one unidentified patient referred on 10/13/11, and interviews, the hospital failed to maintain the referral log by failing to identify the referral of one unidentified patient referred by Hospital A on 10/13/11. Findings:

On 10/26/11 at 8:35 AM, a confidential telephone interview was conducted with Registered Nurse S11. S11 who is an RN in the emergency depart (ED) at Hospital A, stated there was a 26 year old male patient in the ED who attempted suicide, a Physician Emergency Certificate had been implemented, and they were trying to find inpatient psychiatric services for this patient. At approximately 12:30 PM on 10/13/11, the information related to this patient was faxed to admissions department at Promise Hospital and at 3:00 PM, a follow-up telephone call was made. According to RN S11, she spoke with the admissions clerk, S8, who informed her that if the hospital had a bed, they would require a $6000.00 cashier check because the patient was private pay.

Review of the referral log from October 1, 2011 through October 23, 2011 revealed there failed to be evidence the referral from Hospital A on 10/13/11 was documented on the referral log.

Interviews with Admissions Coordinator S7 and Admissions Clerk S8 on 10/25/11 at 2:25 PM revealed in the middle of October 2011, a hospital did call with a referral related to a psychiatric patient; however, a referral form was not completed nor was the referral entered into the referral log.

Based upon review of referral logs, referral intake forms, inpatient census reports, policies and procedures, and interviews, the hospital failed to: 1) accept a referral based upon "no beds" for 1 of 21 patients reviewed (#1) when the hospital had the bed capacity to accept the transfer, and 2) denied the acceptance of an unidentified patient from the ED at Hospital A due to no payor source when the hospital had the capacities and capabilities to provide inpatient psychiatric treatment. Findings:

Interview with the hospital administrator S1 and the Chief Clinical Officer, S2, on 10/25/11 at 11:30 AM, revealed inpatient psychiatric services were provided on the 3rd floor of the hospital. According to S1 there were 10 beds for adult psychiatric patients, 22 for geriatric psychiatric patients and 24 beds for addictive medicine unit (AMU).

The following reflects the reviews of the referral logs and the intake referral forms from April 1, 2011 to October 21, 2011:

Review of the Referral Intake Form for patient #1 revealed on 08/15/11 at 9:20 AM, the emergency department of Hospital B referred a 46 year old female for audio and visual hallucinations. The patient's financial class was identified as "Medicare". The admission was denied due to "cancelled no beds - could not hold". Review of the inpatient census dated 08/15/11 revealed the adult psychiatric unit census was 5, the AMU census was 23, and the Gerol-psychiatric unit census was 11.

On 10/26/11 at 8:35 AM, a confidential telephone interview was conducted with Registered Nurse S11. S11, who is an RN in the emergency department (ED) at Hospital A, stated there was a 26 year old male patient (Unidentified Patient) in the ED who had attempted suicide, an Physician Emergency Certificate had been implemented, and they were trying to find inpatient placement for psychiatric services. At approximately 12:30 PM on 10/13/11, the information related to this patient was faxed to the admissions department at Promise Hospital and at 3:00 PM, a follow-up telephone call was made. According to RN S11, she initially spoke with the admissions clerk, S8, who informed her that if the hospital had a bed, they would require a $6000.00 cashiers check because the patient was private pay. RN S11 further stated she then asked if there was someone else to speak with and the Admissions Coordinator S7 called her back. RN S11 stated S7 told her they would have to place the patient on a waiting list due to non-availability of beds; however, the patient would still require the $6000.00 deposit prior to admission. RN S11 also stated S7 informed her Promise Hospital did not accept patients who had emergency psychiatric conditions even when they were told the patient was medically stable. Review of the ED record from Hospital A revealed according to the Physician Emergency Certificate, the patient was "dangerous to self" and "unable to seek voluntary admission".

Further interview with Admissions Coordinator S7 on 10/25/11 at 2:25 PM, revealed when asked about the admission process specifically for Psychiatry, S7 replied the patient information is faxed to the admissions department, the patient is evaluated and the patient information is then forwarded to the psychiatrist. When questioned about the patient's financial status, S7 replied if the information is not supplied at the time of the referral, when the on-site evaluation is conducted the financial information is obtained at that time for verification. When asked about private pay patients, S7 stated the hospital would require the patient to pay a $6000.00 deposit prior to admission. On 10/26/11 at 1:45 PM, S7 was again interviewed and it was revealed she was under the impression that Psychiatrist S9 was not taking any Medicaid patients. S7 was asked if she remembered any hospital attempting to transfer a psychiatric patient and she responded "yes" that there was an incident that occurred a few weeks ago where a hospital called and told her they had a private pay patient they were trying to find placement for. S7 stated she did tell them there were no beds available and the patient could be placed on a waiting list and confirmed the hospital was told the patient would require a $6000.00 deposit prior to admission.

Review of the inpatient census report for the same date as the referral from Hospital A (10/13/11) it was revealed at the beginning of the morning shift, there were 7 patients on the adult psychiatric unit with one adult male bed available (Room 381-A) During the day, time unknown, two male addictive disease patients were moved from the adult psychiatric unit (Rooms 381-A and 382-B) to the addictive disease unit thereby freeing two male adult psychiatric unit beds.

Interview with the Director of Admissions, S6, on 10/26/11 at 10:30 AM, revealed Promise Hospital was a Long Term Acute Care (LTAC) Hospital that accepted medically complex patients. When asked about the hospital's psychiatric program, S6 stated the program was designed for patients who had chronic psychiatric problems such as being Bipolar or schizophrenia and were not acute. When asked if the hospital had admitted any patients who had attempted suicide by overdose, S6 stated "yes" but the patients were not acute. Further interview with S6 revealed when asked the process of taking a referral from a hospital ED, they would first ensure the patient was medically stable and the psychiatric behaviors were under control. They would communicate with the ED nurse and the physician, evaluate the patient, then the information would be reviewed by the psychiatrist who would either accept or deny the transfer.

Further interview with S6, the Director of Admissions, on 10/27/11 at 3:55 PM, revealed he was aware of a referral the middle of October 2011 related to a hospital attempting to place
a psychiatric patient. The Admissions Clerk S8 initially took the referral information and he instructed the Admissions Coordinator S7 to call the referring hospital back and inform them there were no beds available and they did not accept emergency psychiatric patients since the hospital is considered an LTAC.

Interview with Psychiatrist S9 on 10/25/11 at 4:15 PM, revealed he is the Director of Psychiatric Services. When asked about the adult psychiatric unit, S9 stated it was a 10 bed locked unit; however, he likes to only use a "couple" of the rooms for adult psychiatric patients". When questioned if the hospital accepted emergency psychiatric patients, S9 replied "yes" after the patient had been evaluated in the ER; however, the patient needed to be "sick" and require at least a 21 day stay because the hospital is an LTAC. When asked if he had ever told the admissions department he refused Medicaid patients, S9 replied "well, yes and no. If it is just Medicaid, I don't want to take that many, see 5% in my private practice. I don't take a lot of private insurance." When asked if he was aware of any instances of the admissions department requesting a deposit prior to admission, S9 replied "if they had no insurance, yes."

Review of the policy titled "Admission Criteria" for the psychiatric program revealed the admission criteria for the "Adult Psychiatric Unit" included information if the patient was a "danger to himself", "danger to others", and "gravely disabled". Page 2 of the policy stated "A patient's psychiatric conditions requires comprehensive diagnostic evaluation or stabilization (24 hour medical/psychiatric observation) in a safe, protective environment." "Patient displays behavioral and emotional deficits with limited control and minimal self-care ability requiring inpatient psychiatric treatment that emphasized skill building in the areas of activities of daily living which require 24 hour supervision."

On 10/28/11 at 3:30 PM, the referral for patient #1 was reviewed with the Director of Admissions S6. When asked about the documentation of "no accepting MD" for patient #1, S6 stated the referral was cancelled because there were no beds available; however, review of the inpatient census report for the date of referral (08/15/11) revealed there was a female bed available in room 378-B. Interview with S6 during this review revealed he did not know the reason the patient was denied.

Review of the inpatient census reports and nurse staffing schedules revealed even though the hospital had the capacity and capability to admit patient #1 and one unidentified patient, these referrals were denied due to documentation of no accepting physician due to the patient's payor source and/or no availability of beds.