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Based on review of facility policy, review of Governing Board and Medical Staff bylaws, review of Emergency Medical Services (EMS) documentation, medical record review, review of facility census documentation, and interviews, the facility failed establish policies and procedures for Emergency Medical Treatment and Labor Act (EMTALA), failed to ensure Governing Body and Medical Staff bylaws reflected the requirements for EMTALA, and failed to accept an appropriate transfer for 1 patient (#8) with behavior changes and Dementia for 21 records reviewed.

The findings included:

Patient #8 was admitted to Facility B's Emergency Department (ED) on 7/20/2023 with behavioral issues and dementia. The patient had lived in a Skilled Nursing Facility (SNF) and had previous history of dementia and schizoaffective disorder (mental disorder characterized by abnormal thought processes and unstable mood). The patient had been medically cleared for psychiatric evaluation which was completed on 7/31/2023. On 7/28/2023 a referral to Facility A was received and the patient was accepted for admission to the geriatric unit on 8/2/2023. Emergency Medical Service transport was requested by Facility A. On 8/2/2023 [Facility A] had a discharge for Patient #22, however, the patient's discharge was canceled. EMS was already in transport with the patient from Facility B. Facility A's Patient Coordinator supervisor notified [Facility B] and EMS they could not accept patient related to bed availability and the patient was transported back to Facility B. Facility A had spoken with the Psychiatrist on the Adult 1 unit (inpatient unit for behavioral health patients) to see if the patient could be admitted to the Adult 1 unit. The psychiatrist felt the patient was not medically stable and they could not accept the patient on the Adult 1 unit. Review of the midnight census for Facility A on 8/2/2023, showed the Geriatric Unit had 15 patients (1 bed available), the Adult 1 unit had 21 patients (3 beds available), and Adult 2 had 21 patients (2 beds were blocked, 1 bed available) and had open beds.

Review of the facility's policies showed the facility did not have policies related to EMTALA. Review of 5 employee personnel files showed the employees had not completed EMTALA training.

Review of the Governing Board Bylaws dated 4/2022 and the Medical Staff Bylaws dated 4/2022 showed no documentation of EMTALA reflecting EMTALA rules and regulations at Requirements for Hospitals 489.20 and 489.24.

During an interview on 10/3/2023 at 2:00 PM the Director of Operations confirmed the facility did not have an EMTALA policy and the employees had not completed EMTALA training.

Please see A-2411

Based on review of facility policy, medical record review, review of Emergency Medical Services (EMS) documentation, review of facility census documentation, and interviews, the facility failed to accept an appropriate transfer for 1 patient (#8) with behavior changes and Dementia for 21 records reviewed.

The findings included:

Review of facility documentation showed the facility did not have policies related to EMTALA.

Review of facility policy 'Patient Referral' last revised 5/31/2023 showed "...all patients will be accepted for care, cared for and housed without discrimination on the basis of race, color, religion, sexual orientation, ancestry, or national origin...patients will be admitted to the hospital when their behavioral healthcare needs meet diagnostic criteria as defined by regulatory guidelines and are appropriate for diagnosis and treatment in an acute care setting....inclusion criteria:...cognitive disorders, dementia with delusions, hallucinations, depressed and/or behavioral problems...requires admission due to the following indications...represents a current danger to self or others, or significant property destruction...requires admission for treatment and/or observation...further psychiatric evaluation, medication treatment, specialized treatment..."

Review of facility policy 'Patient Referral When Admission Criteria Not Met' last revised 5/31/2023 showed "...the hospital shall accept those individuals who meet established admission criteria and require services and care that is within our capacity to provide. When services not available at our facility are required, efforts are made to refer the patient to the appropriate agency or facility..."

Review of facility policy 'Acceptance of Patients Transferred from another Hospital' last revised 5/31/2023 showed "...the hospital shall accept patients from other hospitals, clinics, agencies if the patient meets the admission criteria of the services to which he/she will be admitted, and the patient has been accepted by a physician on our staff. The department/unit receiving the call from another facility regarding a transfer into the hospital refers the caller the admissions coordinator for a telephone assessment of the circumstances. The admissions coordinator will determine if the patient meets the admission criteria and ensures that a physician on the staff of the hospital has accepted the patient for admission. The admission coordinator can, at this time, request for any additional records or other date which would be of assistance for the providers during the patient's stay..."

Medical record review of an ED Physician record from Facility B dated 7/20/2023 at 11:21 PM showed the patient was admitted from a Skilled Nursing Facility (SNF) for behavioral issues. The patient had previous history of dementia, hypertension (elevated blood pressure, hyperlipidemia (elevated blood cholesterol levels), diabetes, and schizoaffective disorder. She had been evaluated on 7/17/2023 for a similar episode and remained in the ED for an extended time period. She had been sent back to the SNF twice and the SNF staff told the EMS the patient was confused and combative but was not at baseline mental status. EMS had reported the patient had not been confused. The patient was sent back to the ED. The patient had been treated for a UTI and was restarted on antibiotics. Her Complete Blood Count (CBC) showed no new acute findings, her Urinalysis was positive for an UTI, and Comprehensive Metabolic Panel (CMP) showed no relatively new concerns.

Medical record review showed the patient was readmitted to Facility B's ED on 7/28/2023 at 7:16 AM. The "...medical care of the patient while in a psychiatric hold unit/transfer issues. Patient is still being managed by Case Management. I talked to ED medical director and nurse manager about the better placement within the hospital for this patient..." The patient was an involuntary hold and was medically cleared.

Medical record review of an ED Physicians Record from Facility B dated 7/28/2023 at 7:48 AM showed "...unfortunately this patient has remained in the ER for 7 days due to insurance issues. Patient has ran out of inpatient psychiatric days for her Medicare plan. Nursing home is refusing to take her back..." The patient's diagnoses included Dementia and Aggressive behavior.

Medical record review of a Psychiatric Progress Note from Facility B dated 7/31/2023 at 10:02 AM showed the patient had history of hypertension, hyperlipidemia, diabetes, and schizoaffective disorder. She had been transferred from a skilled nursing facility related to refusing to take her medications and acting out toward the staff. The patient was delusional, irritable, and uncooperative. Her diagnosis was schizoaffective disorder. She was continued on Haldol (antipsychotic medication) and "...patient will need treatment review committee for forced meds..."

Review of a Referral Worksheet from Facility A dated 7/28/2023 at 4:28 AM showed a referral for placement was requested from Facility B. On 8/2/2023 at 9:11 PM showed the patient was not accepted related to the medical acuity.

Medical record review of an ED Physicians record from Facility B dated 8/2/2023 at 2:46 PM showed "...spoke with social services, patient had been accepted at [named Facility A]. Per social services, [named Skilled Nursing facility] will continue with conservatorship. Patient is stable to transfer to psychiatric facility for psychiatric evaluation...medically cleared...diagnoses Dementia, UTI, Aggressive Behaviors..."

Medical record review of an EMS Run Report dated 8/2/2023 at 3:59 PM showed the patient was transported from Facility B to Facility A related to psychosis. One hour into the transport the EMS unit was notified by dispatch where Facility A had canceled the transport related to not having an available bed for the patient around 3:27 PM. The patient was transported back to Facility B.

Medical record review showed the patient was transported back to Facility B's ED by EMS on 8/2/2023. The patient remained in the ED until 8/10/2023 where she was admitted to the facility pending placement.

Review of Facility A's bed capacity showed the facility had 16 beds on the Geriatric Unit, 24 beds on the Adult 1 unit (psychiatric patients), and 24 beds on the Adult 2 unit (substance abuse and general psychiatric unit). On 8/2/2023, the midnight census showed the following: Geriatric Unit 15 patients (1 bed available)
Adult 1 unit 21 patients (3 beds available)
Adult 2 21 patients (2 beds were blocked, 1 bed available).
In addition, the census for 8/2/2023 was as follows:
5:30 AM: 15 patients (1 open bed) on the Geriatric Unit, 21 patients (3 open beds) on the Adult 1 unit, and 20 patients (2 open beds) on the Adult 2 unit
5:30 PM: 15 patients (1 open bed) on the Geriatric Unit, 20 patients (4 empty beds) on the Adult 1 unit, 21 patients (1 open bed) on the Adult 2 unit.

During an interview on 10/2/2023 at 3:00 PM, the Director of Admissions, stated the facility had received a referral packet from Facility B for Patient #8. The request was for a geriatric unit bed. The patient had been approved for acceptance. Facility B had been called and EMS had been called for transport. A discharge for another patient (#22) had been written so there was going to be an open bed. The discharge for Patient #22 was canceled related to placement issues and an approved revised Pre-Admission Screening and Resident Review (PASRR) had not been received. The medical director for the Adult 1 unit was consulted for possible admission to the Adult 1 unit until a geriatric bed became available. The medical director for the Adult 1 unit felt the patient was not an appropriate candidate for the Adult 1 unit and did not accept the patient. The patient was not accepted related to her age, diagnosis of dementia, she was a higher acuity level related to fact she required total assistance with activities of daily living, she was increased risk for falls, she required the use of a gait belt, and she needed a chair alarm. She had called Facility B and informed them they could not accept the patient related to bed availability. EMS had already picked the patient up and were in transport with the patient. She called the EMS dispatch, informed them the patient was not accepted, and to return the patient back to Facility B. She confirmed the patient did not come to the facility on 8/2/2023. She stated "...later in the afternoon, the EMS Regional Supervisor called me and stated the EMS transport team had called her about the patient not being accepted. They had to travel for over 3 hours with the patient and they were within one hour of arrival at our facility. I gave her the details about the patient not being accepted related to the patient on the geriatric unit had not been discharged as expected and we did not have a bed for the patient..."

During a telephone interview on 10/2/2023 at 4:10 PM, the EMS Regional Supervisor stated she was called by the EMS crew on 8/2/2023 who relayed the EMS crew had been informed the admission was canceled and they had been told to return the patient back to Facility B. She had called Facility A and spoke with the admission coordinator supervisor. She was told by the supervisor to 'cancel the transport' related to no bed availability for the patient.

During an interview on 10/3/2023 at 11:20 AM, Psychiatrist #1 stated she was consulted related to Patient #8 and another patient (#22) who was going to be discharged. Patient #22's discharge had been canceled. She had reviewed the patient's medical record. The patient had refused to take both psychiatric and home medications, her blood pressure was 153/91, her urine showed a UTI, her Thyroid Stimulating Hormone (TSH) was elevated and her T4 was low. The patient had an altered mental status and confusion. She felt the patient needed admission at the receiving facility for her medical issues. She stated she felt the patient would not be a good candidate for the Adult 1 unit.

During a telephone interview Psychiatrist #2 stated the patient had been accepted from the intake unit for the Geriatric Unit. The patient had a UTI which had been treated and continued with delirium on top of the UTI. The patient had been deemed medically stable at the sending facility.

During a telephone interview on 10/3/2023 at 1:25 PM, Admission Coordinator #1 stated the patient had been accepted for the Geriatric Unit. She had reviewed the patient's demographic information, the admission criteria, the patient's behaviors, and the patient's labs. She stated if she had questions, she would call the Director of Nursing and/or the physician. The Admission Coordinator stated she was informed the bed on the Geriatric unit was not available for the patient related to the patient (#22's) discharge was canceled. She had contacted her supervisor to see if the patient could be admitted to another unit. She had called the ED supervisor on 8/2/2023 and informed the supervisor the facility did not have a bed for the patient on the Geriatric Unit. She was not sure who had notified the EMS of the patient not being accepted.