HospitalInspections.org

Based on staff interview, patient intake reports, grievance report, staffing information, and facility policy review, the facility failed to comply with 489.20(l) by denying admission request for patients who were labeled as "Self-Pay" on admission intake data sent from referring hospitals for psychiatric patient referrals for seven (7) out of 34 patient referrals while having the staff and beds to treat. This affected Patients #21, #24, # 28, #30, #31, #32, and #34.

Findings Include:

Refer to A2411 for findings.

Based on staff interview, patient intake reports, grievance report, staffing information, and facility policy review, the facility failed to comply with 489.20(l) by denying admission request for patients who were labeled as "Self-Pay" on admission intake data sent from referring hospitals for psychiatric patient referrals for seven (7) out of 34 patient referrals while having the staff and beds to treat. This affected Patients #21, #24, # 28, #30, #31, #32, and #34. The hospital's failure to accept requests for transfer and provide stabilizing treatment as required, posed an immediate and serious threat to their health and safety and inappropriately delayed treatment for their emergency medical conditions.

Findings Include:

Patient #21 was sampled because of being referred from an out-of-town hospital, was self-pay and denied admission reason was documented as "no capacity to treat per Chief Executive Officer (CEO)". The facility was contacted on 06/05/2021 at 03:05 a.m. by another hospital. Nurse reported Patient #21 had psychosis, positive for marijuana and was speaking in third person and had three (3) different personalities. Record review of "Staffing Sheet" for the date 06/05/2021 revealed 12:00 a.m. until 2:59 a.m. on 06/05/2021 the census on NS-5 (adult unit) was 10 patients and was staffed with two (2) registered nurses (RN), one (1) RN left at 9:00 a.m., 1 Licensed Practical Nurse (LPN) and 1 Mental Health Technician (MHT). The acuity level was three (3). Review of facility document entitled "Acuity Staffing Model" revealed recommended staffing requirements for this floor with 10 patients with an acuity level of three (3), should be staffed with 1 RN and 1 MHT/ LPN. The hospital had capability and capacity to accept the referral.

Patient #24 was sampled due to patient was an uninsured referral from an out-of-town hospital and admission denial was documented as no capacity to treat per CEO. The facility was contacted on 06/28/2021 at 02:30 a.m. by an out-of-town hospital requesting placement for 24-year-old female with auditory hallucinations requesting help to get back on medications. Review of Staffing Sheet (date 06/28/2021) for unit NS-5 revealed eight (8) patients, one discharge and one admission acuity level of three and total acuity level of 24, with staffing of two RN's and one MHT. Review of the Acuity Staffing Module revealed the recommended staffing for that shift was one RN and One MHT. Review of " Patient Demographic Profile and Inquiry Call Data Collection" (Dates 06/28/2021) revealed the facility assessed Insured Patient( IP) #7 at 1:06 p.m. and admitted to Unit NS-5 on 6/29/2021 at 9:48 a.m. The hospital had capability and capacity to accept the referral.

Patient # 28 was sampled due to patient was an uninsured referral from an out-of-town hospital and admission denial was documented as "no capacity to treat per CEO". The facility was contacted on 06/08/2021 at 3:30 p.m. from an out-of-town facility requesting admission for an uninsured 35-year-old male with psychosis found crawling on floor stating there were tons of people and cops chasing him. Review of patient staffing report (date 06/08/2021) for Unit NS-3 revealed the census at the beginning of "B" shift (3:00 p.m.-10:59 p.m.) to be 10 Patients, staffed with two RN's, one LPN until 9:00 p.m., and two MHT's. Review of "Activity Staffing Module" revealed the recommended staffing for this shift, census and acuity was one RN, and 1.5 MHT. The hospital had capability and capacity to accept the referral.

Patient #30 was sampled due to patient was an uninsured referral from an out-of-town hospital and admission denial on 6/13/2021 was documented as "no capacity to treat per CEO". The facility was contacted on 06/13/2021 at 8:20 a.m. requesting admission for a 41-year-old uninsured male who attempted suicide by stabbing himself in the leg and thigh. Review of "Staffing Report" (date 06/13/2021) revealed the census for unit NS-4 at 12:00 a.m. was 13 patients with 3 admissions, totaled 16 patients at 3:00 p.m. with acuity level of 3 and total acuity level of 48, and was staffed with one RN from 7:00 a.m. until 9:00 a.m. and two MHT from 07:00 a.m. until 3:00 a.m.. Then 2 RN's and 3 MHT's from 9:00 a.m. till 3:00 a.m. Review of "Acuity Staffing Model" revealed the recommended staffing for this level of acuity and census is two RN's and two MHT/LPN. Record review of Patient Demographic Profiles and standardized intake assessment (date 06/13/2021) reveals the facility admitted Insured Patient (IP) #2 on 06/13/2021 who was assessed at 3:15 p.m. and admitted to NS-4 at 3:54 p.m.. Insured Patient IP #3 was assessed at 12:10 p.m. and admitted to NS-4 at 12:10 p.m. and Patient IP#4 was assessed at 6:21 p.m. and admitted to Unit NS-4 at 6:51 p.m. The hospital had capability and capacity to accept the referral.

Patient #31 was sampled due to patient was an uninsured referral from an out-of-town hospital and admission denial was documented as no capacity to treat per CEO. The facility was contacted on 6/22/2021 at 11:15 p.m. requesting admission for a 44-year-old uninsured suicidal male who was planning to commit suicide by overdose on fentanyl or heroin. Review of "Staffing Sheet" (06/22/2021) revealed Unit NS-5 census at 11:00 p.m. was 10 patients, acuity of 3 and total acuity level of 30 with one RN from 11:00 p.m. till 7:00 a.m.. Review of Acuity Staffing Model revealed the recommended Patient Staffing for unit NS-5 was one RN and two MHT/RN for up to 13 patients. Review of Patient Demographic survey (date 06/22/2021) revealed insured Patient IP#5 was assessed at 10:00 a.m. and admitted to Unit NS-5 at 4:18 p.m. The hospital had capability and capacity to accept the referral.

Patient # 32 was sampled due to patient was an uninsured referral from an out-of-town hospital and who's admission denial was documented as no capacity to treat per CEO. The facility was contacted on 06/11/2021 at 9:10 p.m. requesting admission for a 40-year-old uninsured suicidal male has been restless, not slept for 3 days and police found him at his mother's house with a knife to his throat. Review of staffing sheet (06/11/2021) revealed unit NS-4's census as 10 patients, acuity of 3 and total acuity of 30 and staffed with one RN and one MHT. Review of Acuity Staffing Model's recommendation for that acuity level and census for 11 patients was 2 RN's and 1.5 MHT's. Review of admissions log revealed an admission at 11:09 p.m. for an insured patient. (IP#1). Review of IP#1's intake sheet revealed he arrived at Unit NS-4 at 12:00 a.m. Review of Acuity Staffing Model for NS-4 revealed the staffing requirements at 12:00 a.m. for 12:00 a.m. shift is reduced to one RN and one MHT/LPN. The hospital had capability and capacity to accept the referral.

Patient #34 was sampled due to patient was an uninsured referral from an out-of-town hospital and who's admission denial was documented as "no capacity to treat per CEO". The facility was contacted on 06/09/2021 at 8:26 p.m. requesting placement for an uninsured 37-year-old male suicidal schizophrenia who is having auditory hallucinations. Review of staffing sheet (date 06/9/2021) for Unit NS-3 revealed at 3:00 p.m. unit B shift census was 9 with acuity level of 3 and total acuity of 27 patients and was staffed with two RN's and one MHT/LPN and one orientee. Review of Acuity Staffing Model revealed the recommended staff for that level was one RN and one LPN/MHT. The hospital had capability and capacity to accept the referral.

During an interview on 10/14/2021 at 3:45 p.m., the CEO confirmed he developed a review process for patients greater than 75 miles away. CEO revealed he thought facilities nearer to the patient would be a better fit for the patient support system (family, friends) needs and this location should be opened to serve the needs of the patients of "our" community. When asked about insurance, CEO confirmed his system also took in account non-insured referrals greater than 75 miles away to make sure the patient is appropriate for placement and not have a large bill if their stay did not work out due to logistics. CEO confirmed that some staff members did inform him that his system was an EMTALA violation, and they changed the process since then. The facility has been short staffed and was limited on the number of patients to treat. CEO revealed he has never been asked to do a review on patient admissions anywhere else he has worked. The CEO confirmed that refusal to admit a patient on basis of insurance availability and distance from the facility is an EMTALA violation.

During a telephone interview on 10/7/2021, Assessment Staff (AS) #2 revealed she was the director of the Assessment and Admissions Department when CEO #1 arrived. She states, "He was telling me to start contacting him for any patient that was in an outlying town (one to two hours away) that was not insured. These patients are usually adults, come from an emergency room and hospital that are calling for placement. The facility has already sent us their medical, psyche and insurance information so we already know if the patient is insurance or not. He would tell us to call the facility back and tell them we do not have the beds or another way to say it is we do not have capacity to treat. I told him this was an EMTALA violation, and we would not do it. He kept on harassed me, so I informed the staff to document "No capacity to treat per CEO" to cover us. We have turned away some suicidal people who really needed help. I did not want to be a part of this, so I put in my 30-day notice and filed a formal complaint with corporate compliance. I was told that someone from corporate finally convinced him to stop this."

During an interview on 10/14/2021 at 2:41 p.m., AS #3 confirmed the assessment and screening process is: receiving information from the receiving facility, then labs, history and physical, and diagnosis are reviewed and a physician is contacted. "There was a time when CEO #1 was demanding to be contacted for any patient that was out at least one to one half hours away without insurance he wanted to be contacted and the "no capacity to treat per CEO" was from him." AS #3 revealed she could not be one hundred percent sure that no rooms were available.

During an interview on 10/14/2021 at 2:45 p.m., AS #4 revealed the referral staff was informed by CEO #1, if a patient came from another facility one (1) to two (2) hours away and was self- pay (no insurance) we had to call him. During the interview, RN #1 confirmed the CEO made the decision of no capacity to treat for patient #32.

During an interview on 10/14/2021 at 3:22 p.m., AS #5 confirmed she was instructed to call the CEO for patients in out-of-town facilities, " I can't remember if he elaborated on un-insured patients. The words were "we do not have capacity to treat".

During an interview on 03/14/2021 at 3:35 p.m., AS #6 confirmed if patient was outside a 75-mile radius and un-insured, CEO #1 wanted to be contacted at any time day or night. "I got where I just stopped calling him because I was tired of arguing with him, trying to tell him it was an EMTALA violation. He kept saying it was not. He would say 'No capacity to treat'."

Review of Corporate investigation from companies' "Compliance Hotline Investigation" (06/22/21) alleged Chief Executive Officer #1 (CEO) arrived at the end of March as the Interim CEO. During the first meeting he (CEO #1) told me (assessment staff #2) he wanted to review all my cases who were not admitted and to be called for every uninsured patient. He told me that if a patient was being referred from "far away" their local hospitals should accept. I advised EMTALA law required we accept any patient we had capacity and the capacity to treat. He stated "it's [his] understanding the CEO would determine the hospitals capacity". I advised EMTALA states we cannot deny if we have beds and capacity to treat. He again stated the CEO could make the capacity determination and asked me "Do you understand?". I told him "No, not really." He did not enforce review of uninsured patients at that time. I contacted my Divisional for support. CEO #1 then forced me to have a call every morning in front of three other departments where he grilled me personally regarding any open call that was on our call list for the last 24 hours. He required my staff to contact him regarding any patient who was not accepted even though CEO #1 was not clinical. He initially said if he felt the patient did not need care, then we did not have to call the doctor for review. I advised him physician review was part of the UHS (Universal Health Services) term standards. He then formed a weekly group to review the Term Standards, starting with my department's compliance with them. I advised my Divisional that I had concerns that he was not clinical but was reviewing cases. I was concerned that I would not be able to help my clinicians grow in their skills or probe further to ensure safety. After several discussions where he continued to insist on reviews with him, my divisional spoke with him. He eventually agreed to allow them to review with me. After that decision was made, CEO #1 wanted another department to review cases because he believed that we were declining appropriate patients. We were also having the daily call at this point. I had asked several times for evidence of inappropriately denied patients, but there was none, even after scrutiny by multiple departments. CEO #1 then told me the milieu manager would be meeting with all patients to ask how their admission process was and who referred them to insure we entered the appropriate referral information in MS4. I confronted him at this point to ask him if he didn't feel that I was able to do my job since the oversight of three to four other departments was necessary. He could not identify any deficiencies or issues. Additionally, I spoke to other departments who reports he was not overseeing their departments as he was mine. CEO #1 then instituted that my employees had to call him for every patient who did not have insurance and who's location was over an hour and a half away. He then declined every patient who met these criteria, stating we did not have the capacity despite accepting other insured patient in the same time frame. I advised my divisional who encouraged me to review EMTALA. My divisional and I reviewed it together. During this timeframe which multiple patients were denied due to "no capacity", CEO #1 authorized admitting patients beyond capacity beyond unit bed and staffing capacity because they had insurance. I put in my notice on 6/4/2021."

An internal investigation of these claims resulted in all allegations unsubstantiated.

Policies

Review of facility policy entitled "Appropriate Staffing Levels" (revision 05/13/2021) revealed " ...it is the policy of Brentwood Behavioral Healthcare to ensure the appropriate numbers and qualifications of nursing staff are always available to insure quality patient care. The Chief Nursing Officer (CNO) is responsible for development and ongoing review staffing requirements based on numbers of patients, population served, acuity and measurement of patient outcomes that include patient falls, restraint/seclusion, medication errors, infection rates, patient complaints and grievances, as well as other types of incident occurrences ...each Patient care unit will always have a minimum of one Registered Nurse (RN) ...a minimum of two staff members will be assigned to each unit on all shifts, one of which will be an RN ... Multiple factors influence the functioning of a patient care unit and the CNO/ delegates are responsible to modify staffing as needs arise on day-to day and shift-by shift basis to provide safely. Factors which affect the need to alter staffing levels include but not limited to new admissions increasing unit acuity ...patients on one-to-one monitoring. High risk conditions such as aggressive and/ or violent patients toward self and others ...".

Review of facility policy entitled "Initial Assessment of the Patient" revealed," ... it is the policy of (name of the facility) to thoroughly assess all patients who present to our facility for assistance with psychiatric and /or Chemical Dependency problems. The assessment process is interdisciplinary in nature. Assessment information is used as the basis of making appropriate referrals or initiating plan of care for the patient ... This assessment is to be completed by a clinically qualified staff person who holds a master's degree in a behavioral science field. This assessment serves as the basis for determining the appropriate level of care needed by the person and is offered 24 hours a day, 7 days at the individuals earliest convenience. ...upon completion of the assessment, a disposition will be determined by the physician..."

Review of facility policy entitled "Plan for the Provision of Assessment & Referral Services" dated 12/4/2000 and updated 2/3/2021 revealed "... It is the policy of (facility name) to maintain a system for the appropriate assessment and referral of persons in need of psychiatric and/or chemical dependency treatment. The assessment and referral service believes that every person is an individual with the right to the best quality health care possible. The right is inherent regardless of race, sex, nationality, social or economic status. Therefore, within the limitation of services rendered no person is denied his/her right. The Assessment and Referral Service shall maintain a system for the appropriate assessment and referral of persons in need of psychiatric and/or chemical dependency treatment. The NARC Department believes that every person is an individual with the right to the best quality of health care possible. The Assessment and Referral Service stands to serve the community. In this service it represents one branch of community health network. In that respect, it is responsive to the community and to the network in the planning and implementing of care. Quality care consistent with consumer needs or its primary mandates .... Admissions to any level of care will be made only by a licensed and credentialed physician. Referral to an outpatient program will be made only by a qualified mental health professional after review with a licensed and credentialed physician ... Assessment and referral staff will provide services without regard to age, sex, race, color, religion, national origin, disability, sexual orientation, political affiliation, or economic status...".

Review of facility policy entitled "Assessing an Emergency" dated 12/4/2000 and updated 2/3/2021 revealed " ...An appropriate screening examination should be provided to the individual by Qualified Medical Personnel (QMP) for determination as to whether or not an emergency medical/psychiatric condition exists. The screening examination shall not be delayed in order to inquire as to whether or not the individual has sufficient financial resources to pay for treatment, including the availability of insurance coverage...1. Non-Emergency State. If, after a screening examination and review with the physician, the QMP believes that an individual is clearly not in an emergent state, referrals for treatment should be provided to the individual as deemed clinically appropriate and in compliance with the facility policies and procedures ...2. Emergency state. If, after screening examination, the QMP believes that the individual appears to be in an emergent state, the individual should immediately be referred to a physician for assessment. If a physician is not immediately available, the QMP should contact the on-call or other physician and provide a full report of the patient's clinical condition. The physician should: 1. Make the final determination as to whether the emergent condition exists; 2. Whether the patient meets admission criteria or treatment; and 3. Make the appropriate recommendation for treatment based upon the patient's clinical condition..."