HospitalInspections.org

Based on Facility Policy, Medical Record (MR) review from referring Hospital (Hospital B), Laurel Oaks Intake Activity Log, Emergency Medical Treatment and Labor Act (EMTALA), Medical Staff Rules and Regulations of Laurel Oaks Behavioral Health, and interviews it was determined the facility failed accept a patient requiring specialized services.

Findings include:

Please refer to tag A2411.

Based on Facility Policy, Medical Record (MR) review from referring Hospital (Hospital B), Laurel Oaks Intake Activity Log, Medical Staff Rules and Regulations of Laurel Oaks Behavioral Health, and interviews it was determined the facility failed accept a patient requiring specialized services.

This affected 1 of 7 patients reviewed who were referred from a hospital Emergency Department (ED) to Laurel Oaks Behavioral Health Center including MR # 1 and had the potential to affect all patient referred to this facility.

Findings include:

Facility Policy:

Acute Treatment Program
Admission Criteria/Exclusion Criteria

Facility Policy #: IN-RE.001E
Reviewed 02/19

Laurel Oaks Behavioral Health Center will not discriminate in the provision of services regardless of the consumer's age, race, handicap, national origin, sex, social status, diagnostic category, ...

It is the policy of Laurel Oaks Behavioral Health Center to delineate specific criteria for admission to the Acute Treatment Program. ... The facility does not discriminate on admission on the basis of race, religion, national origin, sexual orientation, language of preference, or disability. The admission process is also explained in a language known by the patient and his or her legal guardian and/or agency representative.

Medical Staff Rules and Regulations of Laurel Oaks Behavioral Health Center
Revised: 6/20/19
Approved: 4/1/21

...1. Criteria for Admission...

1.3. The Facility, through the Medical Director or the Facility CEO, reserves the right to refuse or to recommend to the attending Member that a patient be referred to another facility because his/her needs cannot be met and/or because treatment cannot be adequately provided by this Facility. In no case will refusal be for reasons of race, color, creed, national origin, payor source or any other basis prohibited by applicable law or regulation.

2. Admission

...2.1.3 The patient must be able to communicate...

Facility Policy: Admission Process
Policy #. IN-RE.002
Review date: 02/19

...Procedure:
A. All referrals' nature and disposition received by the program are to be documented in a confidential log maintained on the computer in the Intake/Admitting Office.

...C. When a client is found to be ineligible for inpatient admission, the Intake/Admitting personnel will refer to the affiliate staff or to the physician's office (on-call physician or requested physician) for outpatient therapy. If the client is not financially able to pay for services, referral to appropriate community organization will be made. All referrals will be documented on client intake sheet and data log.

...E. The intake program to be followed when accepting referrals from outside agencies or organizations are the same as those performed on other referrals to the program.

F. The Business Office personnel will verify insurance benefits for clients seeking admission and will collect co-pays and deductibles upon admission from client/family, if insurance coverage is not 100%.


1. Review of Hospital B MR revealed PI (Patient Identifier) # 1 presented to the Emergency Department (ED) on 7/8/21 at 9:07 PM with a chief complaint of Psychiatric evaluation for auditory and visual hallucinations. Vital signs: Blood Pressure 110/73, temperature 98.3, pulse 91, respiratory rate 12, and pulse oximetry 98%.

Review of the Hospital B Psychiatric Evaluation dated 7/8/21 at 9:07 PM revealed "Patient is an 11 year old...with a chief complaint of 'he is seeing stuff and talking to himself '. A translator was used as the family does not speak English well...Patient reports that people are trying to get him and kill him...Father would like the patient transferred to a pediatric facility to assist with psychiatric care as he reports that the hallucinations are getting worse."

Review of the ED Course notes dated 7/8/21 at 10:08 PM revealed "Spoke with case management. They will call around to see if there is anybody that can take patient in transfer for Psychiatric care."

Review of the ED Course notes dated 7/8/21 at 10:31 PM revealed "...case management called back and reports that when labs return they need to be faxed to Laurel Oaks...for review as they might can accept patient in the morning."

Review of the Laurel Oaks Bed Census Report dated 7/8/21 revealed Laurel Oaks had 9 Acute Child beds available and 15 Acute Adolescent beds available at the time of the referral.

Review of the ED Care Timeline dated 7/9/21 at 12:37 AM revealed the information was faxed to Laurel Oaks.

Review of the ED Quick Updates dated 7/9/21 at 3:32 AM revealed the nurse documented "spoke with intake person, (he/she) stated 'parents need to call, parent needs to come, extension 315 or 213, a translator will be needed, 8 AM we can find out if were getting them a bed' charge nurse notified."

Review of the ED Course notes dated 7/9/21 at 3:45 AM revealed the ED provider documented "Laurel Oaks called back and requested we call back at around 8 since they do not have a translator at this time and family needs a translator for intake."

Review of the ED Quick Updates dated 7/9/21 at 7:40 AM revealed the ED nurse documented "family at bedside, updated that Laurel Oaks will call at 8 AM with translator."

Review of the ED Care Timeline, Discharge Planning, dated 7/9/21 at 9:07 AM revealed the staff documented "...Laurel Oaks unable to accommodate Spanish speaking only...CM (Case Management) to continue looking for placement."

Review of the Laurel Oaks Bed Census report dated 7/9/21 revealed Laurel Oaks had 9 available Acute Child beds and 15 available Acute Adolescent beds.

Review of the ED Quick Updates dated 7/9/21 at 9:08 revealed the nurse documented "family at bedside, spoke with case management, looking for placement in another facility, Laurel Oaks is unable to take the patient at this time."

Review of the ED Care Timeline dated 7/10/21 at 6:10 PM revealed the nurse documented "...Father decided to have pt (patient) discharged and he will seek help for pt on out pt basis."

Review of the Laurel Oaks Intake Activity Log dated 7/9/21 at 3:01 AM revealed the referral call for PI # 1 was documented from Hospital A.

Further review of the Intake Activity Log revealed the Disposition/Reason Non Admit for PI # 1 was coded as RETRS RAFNL.

Review of the Intake Log Table Element Selection definitions provided to the surveyor on 7/29/21 revealed code RETRS description was "Returned to Referral Source." And RAFNL description was "Refused Action Financial."

In an interview conducted on 7/29/21 at 11:45 AM, EI # 3, Intake Director, was asked if Laurel Oaks had the capacity and capability to accept PI # 1 on 7/9/21 at 3:01 AM, EI # 3 responded "yes." EI # 3 was then asked what was the reason the patient was not accepted, EI # 3 responded, "We did accept, the family refused due to financial reasons. We tried to explain we could set up something for payment."

EI # 3 was also asked if the intake person spoke with the family or patient, EI # 3 responded, "we spoke to the hospital staff."

An interview was conducted on 7/29/21 at 1:30 PM with EI # 1, Executive Director, who confirmed Laurel Oaks had bed space available and the capability to accept PI # 1 at the time of the referral. EI # 1 was unable to explain how the billing and payment for services was explained to the family of PI # 1.

On 7/29/21 at approximately 2:00 PM a typed noted, signed by EI # 3 and dated 7/29/21, was provided to the surveyor. The document was not part of the Intake Activity Log or a part of the Electronic Health System.

Review of the note revealed, "On July 9, 2021, on or about 1501 (3:01 PM), I spoke with (referring hospital employee) at Southeast Health who referred a patient that was suicidal and exhibiting behavioral problems. I requested that the labs be faxed over for review to ensure the child was medically cleared. Once reviewed and accepted by the physician, I contacted (referring hospital employee) back to inform (him/her) we can accept the patient. (Referring hospital employee) then relayed the parents question in regards to insurance. I informed (him/her) that we accept regardless of insurance and upon admission the family could meet with our business office to make financial arrangements. There was no delay in the acceptance of the patient."

There was no documentation provided by Laurel Oaks to the surveyor of any conversations between the Intake staff of Laurel Oaks and the referring hospital documented on or near the date of the referral.