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Based on observation, record review and interview, facility staff failed to accept the transfer of 1 of 4 patients (Patient #1) who required inpatient psychiatric treatment in a total sample of 20 medical records reviewed.

Findings Include:

Facility staff failed to accept the transfer of a patient who required inpatient psychiatric treatment. See Tag-2411.

Based on observation, record review and interview, facility staff failed to accept the transfer of 1 of 4 patients (Patient #1) who required inpatient psychiatric treatment in a total sample of 20 medical records reviewed.

Findings Include:

A review of the facility's policy titled, "Emergency Services and Patient Transfers- EMTALA" last revised 09/06/2021 revealed, "...Transfers to the Hospital: i. The Hospital shall not refuse to accept an appropriate transfer of an individual ... ii. Upon notification from a transferring physician ... the Hospital shall respond to the transferring hospital and transferring physician with the status of the transfer request and either accept or refuse the transfer ..."

A review of Patient #1's medical record revealed Patient #1 was a 24-year-old male who presented voluntarily (no referral from an outside facility) to Hospital B on 02/24/2025 at 8:24 PM for anxiety, depression, and suicidal ideation after having a conflict with family members. Patient #1 was transferred via van to Hospital A for inpatient admission on 02/25/2025 at 12:15 AM. Patient #1 was transported back via van to Hospital B on 02/25/2025 at 12:47 AM after Hospital A stated that Patient #1 was not medically cleared for admission. Patient #1 was subsequently admitted voluntarily to a different inpatient psychiatric hospital on 02/25/2025 at 9:11 AM.

A review of the medical record from Hospital B (sending facility) revealed, "HPI (History of Present Illness) on 02/25/2025 at 12:56 AM by Psychiatrist J: "...Patient was accepted at [Hospital A] and subsequently transferred there but for some reason, he was sent back with the [van driver]. Apparently there was some request of 'medical clearance' for unclear reasons. The writer received no communication in this regard..."

A review of Hospital A's (receiving facility) "BH Division Incident Report" filed on 02/25/2025 at 12:23 AM by Intake Coordinator M revealed, "Incident Type: EMTALA:..."
-"Referral was received at 2207 (10:07 PM) and I [Intake Coordinator M] began reviewing it at 2208 (10:08 PM).
-I called unit and sent text to House Sup (supervisor) at 2239 (10:39 PM) letting them know we would be accepting pt (patient).
-I spoke with [Hospital B] and confirmed pt's health status at 2245 (10:45 PM) as I noticed the referral stated he had not been medically cleared. Per [Hospital B's RN (Registered Nurse) K], pt was in fact not medically cleared and was still presenting with similar symptoms (incl. (including) Productive cough, trouble breathing). I let [Hospital B's RN K] know I would staff [sic] with [Psychiatrist G] and get back to him.
-I called [Psychiatrist G] at 2248 (10:48 PM) and gave him all the above updates. [Psychiatrist G] stated the pt would need to be medically cleared before coming to us d/t (due to) his symptoms.
-I called [RN K] from [Hospital B] at 2252 (10:52 PM) and let him know the pt would need medical clearance before admitting with us. [Hospital B's RN K] acknowledged understanding and said he would 'work on it.'
-I called house sup at 2256 (10:56 PM) from the intake cell to let her know all of the above updates and that [Patient #1] would no longer be needing N2N (nurse to nurse), as we are awaiting medical clearance.
-Pt arrived here by van from [Hospital B] at 1:49 [sic].
-Van driver was informed by me that pt had not been medically cleared and we would alert house sup so that she could give us a directive. Van driver stated that he would call [Hospital B] in the meantime.
-When house sup made it to intake (shortly after), the van driver had left and was no longer in the ambulance entrance.
-From there, there was a myriad of phone calls between our staff and the staff at [Hospital B]. They stated they did not know pt needed medical clearance and also stated we turned the pt away ..."

Observation of the security footage of Hospital A's ambulance sally port and Intake Area revealed:
02/25/2025 at 12:23 AM: Van from Hospital B pulls up to the ambulance port and waits outside the gate.
02/25/2025 at 12:24 AM: Van driver from Hospital B rings bell outside of the ambulance port (no audio).
02/25/2025 at 12:31 AM: Van from Hospital B backs up and leaves Hospital A.
02/25/2025 at 12:49 AM: House Supervisor H attempts to go out to the ambulance sally port entrance.

During an interview on 03/11/2025 at 11:24 AM with Director of Risk B, when asked about the incident with Patient #1, Director of Risk B stated, "I believe that this was a miscommunication issue. We attempted to go out to assess the patient, but they had already left. We understand that we need to evaluate our patients when they come to us."

During an interview on 03/12/2025 at 1:06 PM with Hospital B's Driver L, when asked about Patient #1, Driver L stated, "We arrived at [Hospital A] and spoke with someone over the buzzer. We got told that the patient was not medically cleared, and they could not accept the patient. We took him back to [Hospital B], and [Hospital B] took the patient back from us."

An interview was conducted on 03/13/2025 at 8:19 AM with Hospital B's Psychiatrist J. When asked about Patient #1, Psychiatrist J stated, "We don't do a direct to doctor report. We talk to the intake department. The patient was reviewed by the intake department at [Hospital A]. I was told that [Patient #1] was accepted at [Hospital A]. He was medically stable when I evaluated him and from my understanding he was accepted at [Hospital A]."