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Based on record review and interview the hospital failed to comply with 42 CFR ?489.24, Special responsibilities of Medicare hospitals in emergency cases, by failing to accept appropriate transfers of patients requiring specialized psychiatric capabilities offered by the hospital when the hospital had both the capacity and capability to accept patients. (cross reference findings at A2411)

Based on record review and interview the hospital failed to accept transfer of an individual who requires specialized capabilities if the receiving hospital has the capacity and capability to treat the individual as evidenced by the hospital failing to accept patients when beds were available as evidenced by review of 25 sampled Intake packets (information sent from requesting hospital) for patients refused admission on days when other patients were admitted which revealed the following: 3 of 25 were refused admission when an " admission " bed was open (#16, #18, #25) and 20 of 25 were refused admission with any bed in the hospital open (#1, #2, #3, #7, #8, #9, #10, #11, #12, #13, #14, #16, #17, #18, #20, #21, #22, #23, #24, #25). On 02/02/11 at 12:40 p.m. the sample was expanded to include all patients currently in the hospital to investigate compliance with the hospital ' s policy of using " admission " beds and refusing patients when the "admission" beds were full. There were 26 patients currently admitted. Record review revealed 8 of 26 current patients were admitted to other than " admission " beds (#R1, #R2, #R7, #R8, #R14, #R16, #R17, #R24) and 8 current patients admission room number could not be found in the medical record. (#R5, #R9, #R10, #R21, #R22, #R23, #R25, #R26). Findings:

The hospital has 14 rooms capable of 28 patients. Each room has an " a " bed and a " b " bed. There is no gender mixing. In an interview on 02/01/11 at 1:25 p.m. with S2DON he stated that the hospital has " designated " admission beds that all admits must go to. He defined these as bed 4a, 4b, 10a, and 10b. S2DON stated that the reason for this was that these rooms had video capability that is displayed at the nursing station. S2DON further stated that prior to 12/01/11 the " admission " beds were 2a, 2b, 3a, and 3b which had no video capability. S2DON stated that " if the 4 admission beds are full the psychiatrist would have to give an order to move a patient out of an admission bed, to another room, before another patient could be accepted into the hospital. " S2DON further stated that " patients in an " admission " room are monitored per the physicians observation orders, are allowed in the milieu with all other patients, have meals with the other patients, and are allowed about the milieu even if 1:1 observation is ordered as they would be accompanied by the assigned Mental Health Technician (MHT) if on 1:1 status. "

In an interview on 02/01/11 at 8:15 a.m. with S1Admin, S2DON and S3RN, Clinical Coordinator, the intake process was discussed. S2DON stated that when another hospital has a request for a transfer they are asked to fax over medical information so St. James Behavioral Health Hospital will " have a working diagnosis " of the patient. S2DON stated they accept male and female patients 18+ years old. S1 Administrator stated that from Monday through Friday during regular business hours (8:00 a.m. - 4:30 p.m. per S10, Intake coordinator) the Intake Coordinator (S10) receives all information faxed from the requesting hospital. S3RN, Clinical Coordinator, then reviews the information and does a medical screening of the information received. S1Admin further stated that after regular business hours the nursing staff requests that the sending hospital fax information and the nursing staff reviews it then call the AOC (administrator on-call) and give a verbal report of the patient. The AOC makes the decision whether to accept or refuse to accept the patient. S1Admin stated if there is a question regarding the medical or psychological status of the patient, then the AOC calls either the psychiatrist or medical doctor. If the patient is accepted by hospital administration, the Psychiatrist and medical doctor are called for admission orders.

In an interview on 02/01/11 at 12:30 p.m. with S10, Intake Coordinator, she stated she works Monday through Friday from 8:00 a.m. to 4:30 p.m. and is responsible for patient Intake. S10 stated she has no clinical background and was hired as Intake Coordinator on December 16, 2010. S10 further stated that this is her first job as Intake Coordinator. S10 stated that when she arrives in the morning she checks for any patients admitted during the night and requests for transfers from other hospitals.

S10 further stated that " if someone calls for a transfers and the hospital (St. James Behavioral Health Hospital) is not full she would then request the requesting hospital to fax information related to the medical status of the patient, i.e., labs, EKG (electrocardiogram) if done, CXR (chest x-ray) if done, lists of medications, physician notes and nurses notes. " S10 stated that S2DON or S3RN then review the information and decide if the patient can be accepted. S10 stated that she cannot request payor source information. S10 further stated that " all beds should be full before a patient is refused. " S10 then stated the hospital uses 4 " admission " beds and that patients go to an " admission " bed for 48 hours and that the hospital cannot take any new patients as long as the 4 " admission " beds are full. (in conflict with her previous statement) S10 stated she has to ask S2DON or S3RN, Clinical Coordinator, about the status of " admission beds. "

In an interview on 02/01/11 at 12:40 p.m. with S3RN, Clinical Coordinator, she stated the hospital uses the " admission " beds (4a, 4b, 10a, and 10b) because they are closest to the nurses ' station and have video monitoring displayed at the nursing station. She further stated that patients are kept in an " admission " bed for 48 - 72 hours. S3RN stated that if the 4 " admission " beds are full the hospital cannot take another admit patient unless the psychiatrist orders one of the patients in an " admission " bed to be moved to another room. S3RN stated that patients in the " admission " rooms are allowed about the milieu with other patients.

In an interview on 02/01/11 at 1:25 p.m. with S2DON he stated that the hospital has " designated " admission beds that all admits must go to. He defined these as bed 4a, 4b, 10a, and 10b. S2DON stated that the reason for this was that these rooms had video capability that is displayed at the nursing station. S2DON further stated that prior to 12/01/10 the " admission " beds were 2a, 2b, 3a, and 3b which had no video capability. S2DON stated that " if the 4 admission beds are full the psychiatrist would have to give an order to move a patient out of an admission bed, to another room, before another patient could be accepted into the hospital. " S2DON further stated that " patients in an " admission " room are monitored per the physicians observation orders, are allowed in the milieu with all other patients, have meals with the other patients, and are allowed about the milieu even if 1:1 observation is ordered as they would be accompanied by the assigned Mental Health Technician (MHT) if on 1:1 status. "

In an interview on 02/02/11 at 1:20 p.m. with S1Admin, S2DON and S3RN, Clinical Coordinator, it was confirmed that the Admission Policy does not designate which rooms are " admission " rooms. S1Admin, S2DON and S3RN, Clinical Coordinator were asked why some patients are admitted to beds other than " admission " beds and some are refused admission. S2DON stated that " staff are non-compliant " and that " as recently as last night a patient (#R27) was admitted to a room that was not an " admission " room. "

During the same interview S1Admin, S2DON and S3RN, Clinical Coordinator, were asked to provide the policy/procedure that designates which rooms are " admission " rooms, the policy/procedure relating to the criteria for moving a patient out of an admission room, the policy/procedure on when/how to move a patient out of an " admission " room, and documentation of phone calls to the attending physicians regarding moving patient ' s out of the " admission " rooms. All stated there is no written policy/procedure for these items as they were never developed and there is no documentation of phone calls to the attending physicians regarding moving patient ' s out of the " admission " rooms.

Review of a St. James Behavioral Health Hospital policy titled " Admission Process " , policy number 1.2, originated June 2006, revised January 2010, presented as current policy reads in part: " Subject: Admission Process. Section: Patient Rights/Organizational Ethics. Policy: It is the policy of the Hospital to assess, admit, or refer patients on a twenty-four (24) hour per day, seven (7) day per week basis regardless of third party reimbursement status, ability to pay for services, race, religion, gender, sexual orientation, ethnicity, disability, and age 18 years and older. Procedure: To define the procedures for twenty-four (24) hour coverage of psychiatric emergencies, admission, or referrals. Procedure: 1. During business hours, all referral calls are routed to the intake coordinator, who is responsible for completion of the inquiry form and certification of benefits. 2. After business hours, referral calls are taken by the unit charge nurse. 3. All admissions to the facility are screened by the administrator and the Director of Nursing for clinical appropriateness. The on-call physician is contacted for admission approval. 4. Prior to admission to the unit, the physician is contacted for admission orders ...9. The facility maintains four designated admit beds for close observation of new patients. All new admissions are placed in a designated admission bed for seventy-two (72) hours unless a physician ' s order is received to release the patient earlier. 10. Scheduled/direct admissions will report to the facility and follow the same admission process previously described. "

Review of a St. James Behavioral Health Hospital policy titled " Admission Criteria " , policy number 1.5, originated June 2006, last reviewed May 2010, presented as current policy, reads in part: " Subject: Admission Criteria. Section: Patient Rights/Organizational Ethics. Policy. It is the policy of the Hospital to admit patients, aged 18 or older, whose mental condition warrants acute, inpatient psychiatric care. Patients appropriate for admission are accepted regardless of third party reimbursement status, ability to pay for services ...Purpose. To establish the criteria for appropriate admission to the Hospital. Procedure. 1. The Director of Nursing, RN Clinical Coordinator or Administrator will administratively screen patients for evidence of acceptable conditions of admission. This screening can occur concurrently or retrospectively ...3. Patients who show evidence of symptoms of acute psychiatric disorders will be accepted for admission if they are medically cleared and who are over 18 years of age ... "

Review of a St. James Behavioral Health Hospital policy titled " Emergency Room Referrals " , policy number 1.7, originated June 2006, no revision date, presented as current policy, reads in part: " Subject: Emergency Room Referrals. Section: Patient Rights/Organizational Ethics. Policy. It is the policy of the Hospital to act as a resource for psychiatric patients identified in an Emergency Room (ER). Purpose. To deliver psychiatric services to individuals who meet acute adult inpatient criteria. Procedure. 1. When a psychiatric patient is identified by ER staff, St. James Behavioral Health Hospital, Inc. may be contacted for potential placement. 2. St. James Behavioral Health Hospital, Inc. staff will complete the Inquiry Log form and notify the Administrator on-call of the patient ' s presence in an ER. 3. A Pre-Admission Assessment by telephone will be completed by the RN on duty ... "

Review of 25 sampled Intake packets (information sent from requesting hospital) for patients refused admission on days when other patients were admitted revealed the following: 3 of 25 were refused admission when an " admission " bed was open (#16, #18, #25) and 20 of 25 were refused admission with any bed in the hospital open (#1, #2, #3, #7, #8, #9, #10, #11, #12, #13, #14, #16, #17, #18, #20, #21, #22, #23, #24, #25).

Patient #16 (male) was refused admission on 11/06/10 at 1545 (3:45 p.m.). Review of Section III of the Inquiry Call Form revealed " Admission Approved? - No. If No, WHY? - no admit bed. " The AOC line is marked (S1Admin). Review of the census data for 11/06/10 revealed room 2a and 2b ( " admission beds " ) were available, 3a and 3b were full. Further review revealed the following beds were available for a male patient: 2a and 2b, 6b, and 13b.

Review of the information sent from the requesting hospital revealed payor source information was included and identified patient #16 as uninsured.

In an interview on 02/02/11 at 9:02 a.m. with S2DON and S3RN, Clinical Coordinator, both stated there was an " admission " bed open. S2DON and S3RN, Clinical Coordinator, both stated that patient #16 should have been accepted because an " admission " bed was open.

Patient #18 (female) was refused admission on 11/03/10 at 2020 (8:20 p.m.). Review of Section III of the Inquiry Call Form revealed " Admission Approved? - No. If No, WHY? - no admit bed. " The AOC line is blank. Review of the census data for 11/03/10 revealed 2a, 3a, and 3b were full. Further review revealed the following beds were available for a female patient: 2b ( " admission bed " ), 11b, and 14b.

Review of the information sent from the requesting hospital revealed payor source information was included and identified patient #18 as having Medicaid.

In an interview on 02/02/11 at 9:03 a.m. with S2DON and S3RN, Clinical Coordinator, both stated there was an " admission " bed open. S2DON and S3RN, Clinical Coordinator, both stated that patient #18 should have been accepted because an " admission " bed was open.

Patient #25 (female) was refused admission on 11/29/10 (no time documented). Review of Section III of the Inquiry Call Form revealed " Admission Approved? - No. If No, WHY? - no admit bed. " Review of the census data for 11/29/10 revealed 2b and 3a were full. Further review revealed the following beds were available for a female patient: 2a ( " admission bed " ), 3b ( " admission bed " ), 7a, 13a, 13b, 14a and 14b.

Review of the information sent from the requesting hospital revealed payor source information was included and identified patient #25 as uninsured.

In an interview on 02/02/11 at 8:35 a.m. with S2DON and S3RN, Clinical Coordinator both stated there was an " admission " bed open. S2DON and S3RN, Clinical Coordinator, both stated that patient #25 should have been accepted because an " admission " bed was open.

20 of 25 were refused admission with any bed in the hospital open (#1, #2, #3, #7, #8, #9, #10, #11, #12, #13, #14, #16, #17, #18, #20, #21, #22, #23, #24, #25) (the documentation for #16, #18 and #25 is in the above section) (the sample was expanded and revealed current patients were admitted to any open bed)

Patient #1 (female) was refused admission on 01/02/11 (no time documented). Review of Section III of the Inquiry Call Form revealed " no admit bed. " Review of the census data for 01/02/11 revealed 4a, 4b, 10a, and 10b were full. Further review revealed the following beds were available for a female patient: 2b, 3b, 11a, 13a, and 13b.

Review of the information sent from the requesting hospital revealed payor source information was included and identified patient #1 as uninsured.

In an interview on 02/02/11 at 8:35 a.m. with S2DON and S3RN, Clinical Coordinator both confirmed that the hospital did have an open bed.

Patient #2 (male) was refused admission on 01/07/11 (no time documented). Review of Section III of the Inquiry Call Form revealed " no admit bed. " There is no documentation of contact with the AOC. Review of the census data for 01/07/11 revealed 4a, 4b, 10a, and 10b were full. Further review revealed the following beds were available for a male patient: 7a, 7b, 1a, and 1b.

Review of the information sent from the requesting hospital revealed payor source information was included and identified patient #2 as uninsured.

In an interview on 02/02/11 at 8:40 a.m. with S2DON and S3RN, Clinical Coordinator both confirmed that the hospital did have an open bed.

Patient #3 (female) was refused admission on 01/03/11 (no time documented). Review of Section III of the Inquiry Call Form revealed " no admit bed. " Review of the census data for 01/03/11 revealed 4a, 4b, 10a, and 10b were full. Further review revealed the following beds were available for a female patient: 3b, 11b, 13a, and 13b.

Review of the information sent from the requesting hospital revealed payor source information was included and identified patient #3 as uninsured.

In an interview on 02/02/11 at 8:50 a.m. with S2DON and S3RN, Clinical Coordinator both confirmed that the hospital did have an open bed.
Patient #7 (female) was refused admission on 01/20/11 (no time documented). Review of Section III of the Inquiry Call Form revealed " Admission Approved? - No. If No, WHY? - no admit bed. " Review of the census data for 01/20/11 revealed 4a, 4b, 10a, and 10b were full. Further review revealed the following beds were available for a female patient: 11a.

Review of the information sent from the requesting hospital revealed payor source information was included and identified patient #7 as uninsured.

In an interview on 02/02/11 at 8:50 a.m. with S2DON and S3RN, Clinical Coordinator both confirmed that the hospital did have an open bed.

Patient #8 (male) was refused admission on 12/01/10 at 2000 (8:00 p.m.). Review of Section III of the Inquiry Call Form revealed no documentation of the reason for patient #8 not being accepted. Review of the census data for 12/01/10 revealed 4a, 4b, 10a, and 10b were full. Further review revealed the following beds were available for a male patient: 1a, 6b, 8b, 13a, 13b and 14a.

Review of the information sent from the requesting hospital revealed payor source information was included and identified patient #8 as having Medicaid.

In an interview on 02/02/11 at 8:50 a.m. with S2DON and S3RN, Clinical Coordinator both confirmed that the hospital did have an open bed.

Patient #9 (female) was refused admission on 12/03/10 at 2000 (8:00 p.m.). Review of Section III of the Inquiry Call Form revealed " Admission Approved? - No. If No, WHY? - no admit bed. " Review of the census data for 12/03/10 revealed 4a, 4b, 10a, and 10b were full. Further review revealed the following beds were available for a female patient: 11b.

Review of the information sent from the requesting hospital revealed payor source information was included and identified patient #9 as having private insurance.

In an interview on 02/02/11 at 8:53 a.m. with S2DON and S3RN, Clinical Coordinator both confirmed that the hospital did have an open bed.

Patient #10 (male) was refused admission on 12/14/10 (no time documented). Review of Section III of the Inquiry Call Form revealed " Admission Approved? - No. If No, WHY? - no admit bed. " Review of the census data for 12/14/10 revealed 4a, 4b, 10a, and 10b were full. Further review revealed the following beds were available for a male patient: 1b.

Review of the information sent from the requesting hospital revealed payor source information was included and identified patient #10 as uninsured.

In an interview on 02/02/11 at 8:55 a.m. with S2DON and S3RN, Clinical Coordinator both confirmed that the hospital did have an open bed.

Patient #11 (male) was refused admission on 12/14/10 at 0500 (5:00 a.m.). Review of Section III of the Inquiry Call Form revealed " Admission Approved? - No. If No, WHY? - placed. " Further review of the Inquiry Call Form revealed no documentation of contact with the AOC. Review of the census data for 12/14/10 revealed 4a, 4b, 10a, and 10b were full. Further review revealed the following beds were available for a male patient: 1b.

Review of the information sent from the requesting hospital revealed payor source information was included and identified patient #11 as having private insurance.

In an interview on 02/02/11 at 8:56 a.m. with S2DON and S3RN, Clinical Coordinator both confirmed that the hospital did have an open bed.

Patient #12 (female) was refused admission on 12/16/10 (no time documented). Review of Section III of the Inquiry Call Form revealed " Admission Approved? - No. If No, WHY? - no admit bed. " Review of the census data for 12/16/10 revealed 4a, 4b, 10a, and 10b were full. Further review revealed the following beds were available for a female patient: 2b, 6a, 6b, 7a and 11b.

Review of the information sent from the requesting hospital revealed payor source information was included and identified patient #12 as having private insurance.

In an interview on 02/02/11 at 8:58 a.m. with S2DON and S3RN, Clinical Coordinator both confirmed that the hospital did have an open bed.

Patient #13 (male) was refused admission on 12/19/10 at 0530 (5:30 a.m.). Review of Section III of the Inquiry Call Form revealed " Admission Approved? - No. If No, WHY? - placed. " Further review revealed a one hour delay in contacting the AOC (time between fax and Inquiry Call Form). Review of the census data for 12/19/10 revealed 4a, 4b, 10a, and 10b were full. Further review revealed the following beds were available for a male patient: 1a and 3a.

Review of the information sent from the requesting hospital revealed payor source information was included and identified patient #13 as having private insurance.

In an interview on 02/02/11 at 8:59 a.m. with S2DON and S3RN, Clinical Coordinator both confirmed that the hospital did have an open bed.

Patient #14 (male) was refused admission on 12/19/10 at 3:00 a.m. Review of Section III of the Inquiry Call Form revealed " Admission Approved? - No. If No, WHY? - no admit bed. " There is no documented evidence of notification of the AOC. Review of the census data for 12/19/10 revealed 4a, 4b, 10a, and 10b were full. Further review revealed the following beds were available for a male patient: 1a and 3a.

Review of the information sent from the requesting hospital revealed payor source information was included and identified patient #14 as having Medicaid.

In an interview on 02/02/11 at 9:01 a.m. with S2DON and S3RN, Clinical Coordinator both confirmed that the hospital did have an open bed.

Patient #17 (female) was refused admission on 11/01/10 at 0358 (3:58 a.m.). Review of Section III of the Inquiry Call Form revealed " Admission Approved? - No. If No, WHY? - no admit bed. " Review of the census data for 11/01/10 revealed 2a, 2b, 3a, and 3b were full. Further review revealed the following beds were available for a female patient: 4a, 4b, and 14b.

Review of the information sent from the requesting hospital revealed payor source information was included and identified patient #17 as having Medicaid.

In an interview on 02/02/11 at 9:03 a.m. with S2DON and S3RN, Clinical Coordinator both confirmed that the hospital did have an open bed.

Patient #20 (male) was refused admission on 11/07/10 at 1900 (7:00 p.m.). Review of Section III of the Inquiry Call Form revealed " Admission Approved? - No. If No, WHY? - no admit bed. " There is no documented evidence of notification of the AOC. Review of the census data for 11/07/10 revealed 2a, 2b, 3a, and 3b were full. Further review revealed the following beds were available for a male patient: 4a and 13b.

Review of the information sent from the requesting hospital revealed payor source information was included and identified patient #20 as having Medicaid.

In an interview on 02/02/11 at 9:05 a.m. with S2DON and S3RN, Clinical Coordinator both confirmed that the hospital did have an open bed.

Patient #21 (male) was refused admission on 11/08/10 at 0345 (3:45 a.m.). Review of Section III of the Inquiry Call Form revealed " Admission Approved? - No. If No, WHY? - no admit bed. " There is no documented evidence of notification of the AOC. Review of the census data for 11/08/10 revealed 2a, 2b, 3a, and 3b were full. Further review revealed the following beds were available for a male patient: 4a, 6b, 8a, 8b, and 12b.

Review of the information sent from the requesting hospital revealed payor source information was included and identified patient #21 as uninsured.

In an interview on 02/02/11 at 9:06 a.m. with S2DON and S3RN, Clinical Coordinator both confirmed that the hospital did have an open bed.

Patient #22 (female) was refused admission on 11/17/10 at 9:30 a.m. Review of Section III of the Inquiry Call Form revealed " Admission Approved? - No. If No, WHY? -no admit bed. " There is no documented evidence of notification of the AOC. Review of the census data for 11/17/10 revealed 2a, 2b, 3a, and 3b were full. Further review revealed the following beds were available for a female patient: 7b, 10a, 10b, 11a, and 14a.

Review of the information sent from the requesting hospital revealed payor source information was included and identified patient #22 as uninsured.

In an interview on 02/02/11 at 9:07 a.m. with S2DON and S3RN, Clinical Coordinator both confirmed that the hospital did have an open bed.

Patient #23 (female) was refused admission on 11/18/10 at 0345 (3:45 a.m.). Review of Section III of the Inquiry Call Form revealed " Admission Approved? - No. If No, WHY? - no admit bed. " Review of the census data for 11/18/10 revealed 2a, 2b, 3a, and 3b were full. Further review revealed the following beds were available for a female patient: 12a.

Review of the information sent from the requesting hospital revealed payor source information was included and identified patient #23 as uninsured.

In an interview on 02/02/11 at 9:08 a.m. with S2DON and S3RN, Clinical Coordinator both confirmed that the hospital did have an open bed.

Patient #24 (female) was refused admission on 11/12/10 (no time documented). Review of Section III of the Inquiry Call Form revealed " Admission Approved? - No. If No, WHY? -placed. " Further review of the Inquiry Call Form revealed no time of intake or no reason patient #24 was not accepted then. Review of the census data for 11/12/10 revealed 2a, 2b, 3a, and 3b were full. Further review revealed the following beds were available for a female patient: 7a and 11b.

Review of the information sent from the requesting hospital revealed payor source information was not included. Further review of the Intake form revealed no time the intake was received or the time the AOC, S2DON, reviewed the information and called S6MD to give report.

In an interview on 02/02/11 at 8:50 a.m. with S2DON and S3RN, Clinical Coordinator both confirmed that the hospital did have an open bed.

On 02/02/11 at 12:40 p.m. the sample was expanded to include all patients currently in the hospital to investigate compliance with the hospital ' s policy of using " admission " beds and refusing patients when these 4 beds (currently 4a, 4b, 10a, and 10b) were full. There were 26 patients currently admitted.

In an interview/record review on 02/02/11 at 12: 40 p.m. with S2DON and S3RN, Clinical Coordinator, a review of the medical record of the 26 current patients revealed the following:

8 patients were admitted to other than " admission " beds:

#R14 was admitted to room 5b on 01/19/11, #R16 was admitted to room 3b on 01/20/11, #R17 was admitted to room 7a on 01/20/11, #R24 was admitted to room 8b on 01/26/11, #R7 was admitted to room 7a on 01/30/11, #R2 was admitted to room 2b on 02/01/11, #R1 was admitted to room 3a on 02/01/11, and #R8 was admitted to room 2a on 02/02/11.

8 patients admission room number could not be found in the medical record. (#R5, #R9, #R10, #R21, #R22, #R23, #R25, #R26) These findings were confirmed by S2DON and S3RN, Clinical Coordinator, at the time of the findings. S2DON stated he could not confirm what room the patients were originally admitted to.