Via Linda Behavioral Hospital

“HOSPITAL MUST MAINTAIN RECORDS CFR(s): 489.20(r)(1) [The provider agrees,] in the case of a hospital as defined in §489.24(b), (including both the transferring and receiving hospitals), to maintain medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer. This Standard is not met as evidenced by: 49638 Based on facility policy and procedure, facility documents, facility document and medical record request, and employee interview, the Department determined the administrator failed to ensure the admission process and provision of needed medical care occurred for a patient in an emergency, pursuant to facility policy. This deficient practice poses a potential risk that a patient will not receive needed emergency medical care, resulting in patient harm or death. Findings include: Policy titled “Admission and Exclusionary Criteria,’ Policy #16345297, last approved August 2024, revealed “...Procedure:...2. When a prospective patient is being referred from another facility, the intake staff will request and review pertinent clinical documentation generated by the referring treatment team...4. The intake staff will utilize the Admission and Exclusionary Criteria policy when reviewing referral information to determine if admission would be clinically appropriate...6. When a potential patient is being referred from another facility or community physician and has been evaluated by the physician within the previous 24 hours, the admitting psychiatrist or designee will contact the referring physician telephonically to discuss their clinical evaluation/reason for the referral and determine medical stability....” Policy titled “Admission Process for the Voluntary Patient,” Policy #14980626, last approved January 2024, revealed “...Procedures:...A. Prior to the Intake Assessment:...1. When the Intake Department receives a phone call, the call is taken and assessed for most appropriate disposition, i.e. scheduling an assessment, a transfer, referring out, etc....2. The Intake Department staff complete the Inquiry Call Form or the Fax Referral/Communication Form and enter the information into MedSeries IV.... Facility document titled “EMTALA,” dated September 9, 2024, revealed that Patient #21 arrived at the facility on September 9, 2024 at 23:58, “Arrival Mode...AMB...Departure Time or Admit Time...Next Day...Disposition:...Admitted...” Review of facility document titled “Intake Activity Log,” from July 2024 to October 2024 revealed no entries for Patient #21. Intake Activity Log information for Patient #21 was requested. None was provided. Request was made for the Inquiry Call Form or the Fax Referral/Communication Form for Patient #21. None was provided. Request was made for the medical record for Patient #21. None was provided. Employees #2 and #3 confirmed during an interview conducted on October 23, 2024, that the referral source for Patient #21 was Abrazo Arizona Heart Hospital and that he/she “was supposed to come for Fentanyl detox, was accepted.” Employees #2 and #3 stated Patient #21 “became involuntary” but were not able to state where or when Patient #21 became involuntary. Employees #2 and #3 were asked if any medical record had been created for Patient #21, they responded “not that we have found.””

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 49638 Based on facility policy and procedure, facility documents, facility document and medical record request, and employee interview, the Department determined the administrator failed to ensure the admission process and provision of needed medical care occurred for a patient in an emergency, pursuant to facility policy. This deficient practice poses a potential risk that a patient will not receive needed emergency medical care, resulting in patient harm or death. Findings include: Policy titled “Admission and Exclusionary Criteria,’ Policy #16345297, last approved August 2024, revealed “...Procedure:...2. When a prospective patient is being referred from another facility, the intake staff will request and review pertinent clinical documentation generated by the referring treatment team...4. The intake staff will utilize the Admission and Exclusionary Criteria policy when reviewing referral information to determine if admission would be clinically appropriate...6. When a potential patient is being referred from another facility or community physician and has been evaluated by the physician within the previous 24 hours, the admitting psychiatrist or designee will contact the referring physician telephonically to discuss their clinical evaluation/reason for the referral and determine medical stability....” Policy titled “Admission Process for the Voluntary Patient,” Policy #14980626, last approved January 2024, revealed “...Procedures:...A. Prior to the Intake Assessment:...1. When the Intake Department receives a phone call, the call is taken and assessed for most appropriate disposition, i.e. scheduling an assessment, a transfer, referring out, etc....2. The Intake Department staff complete the Inquiry Call Form or the Fax Referral/Communication Form and enter the information into MedSeries IV.... Facility document titled “EMTALA,” dated September 9, 2024, revealed that Patient #21 arrived at the facility on September 9, 2024 at 23:58, “Arrival Mode...AMB...Departure Time or Admit Time...Next Day...Disposition:...Admitted...” Review of facility document titled “Intake Activity Log,” from July 2024 to October 2024 revealed no entries for Patient #21. Intake Activity Log information for Patient #21 was requested. None was provided. Request was made for the Inquiry Call Form or the Fax Referral/Communication Form for Patient #21. None was provided. Request was made for the medical record for Patient #21. None was provided. Employees #2 and #3 confirmed during an interview conducted on October 23, 2024, that the referral source for Patient #21 was Abrazo Arizona Heart Hospital and that he/she “was supposed to come for Fentanyl detox, was accepted.” Employees #2 and #3 stated Patient #21 “became involuntary” but were not able to state where or when Patient #21 became involuntary. Employees #2 and #3 confirmed Patient #21 was declined for services upon arrival but failed to produce documentation, including Medical Screening Examination (MSE) or Nurse to Nurse consultation, to verify actions taken by the facility that led to the facility declining services for Patient #21. Employees #2 and #3 were asked if any medical record had been created for Patient #21, they responded “not that we have found.””