Sacramento Behavioral Healthcare Hospital, LLC

“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: 45882 Based on interview and record review, the acute psychiatric (focuses on treatment of mental, emotional and behavioral disorders) hospital (APH) failed to meet the regulatory requirements under the Emergency Medical Treatment and Labor Act (EMTALA) as evidenced by: The APH failed to accept transfer requests for 25 of 25 sampled patients when the facility had the capacity (licensed for 117 beds) and capability of treating these patients when: 1. The facility documentation indicated Patients 5, 12,13,14,15, and 16 were declined admission for inability to pay; 2. The facility documentation indicated Patients 6, 9,17,18, and 19 were declined by due to lack of beds when there were available beds (capacity); 3. The facility documentation did not include rational for Patients 1 and 23’s declination; and 4. The facility documentation indicated patients were declined by without documentation indicating why Patients 2, 3, 4, 7, 8,10, 11, 20, 21, 22, 24, and 25 did not meet the facility scope of services (capability). These failures had the potential to delay care and further compromise the serious and sometimes fatal health conditions of these patients. Findings: During a concurrent interview and review of the electronic intake referral management system requests from acute care hospital emergency departments, intake patient documentation, and facility bed availability with the Intake Director (ID) and Risk Manager Director (RMD), the ID and RMD confirmed the following: Patient 1 Status: Declined on 2/3/25 at 12:06 p.m. Referral Details: “Case built and dropped” Facility Census: 113 Facility Beds Available: 4 Patient 2 Status: Declined on 2/4/25 at 9:49 p.m. Referral Details: “Decline for [name of hospital], patient experiencing severe violence” Facility Census: 113 Facility Beds Available: 4 Patient 3 Status: Declined on 2/7/25 at 7:19 p.m. Referral Details: “62 y/o male with h/o chronic obstructive pulmonary disease (a lung disease characterized by airflow obstruction and breathing difficulties], brought in by ambulance as a code 3 (an emergency vehicles response using lights and sirens; urgent situation requiring immediate action) from a room and board for respiratory distress” Facility Census:109 Facility Beds Available: 8 Patient 4 Status: Declined on 1/6/25 at 8:34 a.m. Referral Details: “Patient with AV (arterio vascular) shunt (a vascular access under the skin used in patients for dialysis (a treatment for patients whose kidneys are not functioning properly)” Facility Census: 108 Facility Beds Available: 9 Patient 5 Status: Declined on 1/7/25 at 11:33 a.m. Referral Details: “SOB (shortness of breath,) after recent pneumonia (lung infection), Abnormal EKG (electrocardiogram., used to diagnose various heart conditions), homeless, unfunded” Facility Census: 107 Facility Beds Available: 10 Patient 6 Status: Declined on 4/21/25 9:38 a.m. Referral Details: “No available male beds” Facility Census: 111 Facility Beds Available: 6 Patient 7 Status: Declined on 2/5/25 at 9:49 a.m. Referral Details: “Decline for [name of hospital], acute respiratory distress (difficulty breathing)” Facility Census: 114 Facility Beds Available: 3 Patient 8 Status: Declined on 4/21/25 at 9:36 a.m. Referral Details: “Incontinent (loss of bladder control, varies from slight loss to complete inability to control urination)” Facility Census: 111 Facility Beds Available: 6 Patient 9 Status: Declined on 4/21/25 at 9:34 a.m. Referral Details: “no available male beds” Facility Census: 111 Facility Beds Available: 6 Patient 10 Status: Declined on 1/7/25 at 1:32 p.m. Referral Details: “per caretaker: Patient has “high functioning autism” (milder symptoms and greater independence), being evicted” Facility Census: 107 Facility Beds Available: 10 Patient 11 Status: Declined on 2/5/25 at 8:56 a.m. Referral Details: “With ingrown toenail, possible infection and refusing treatment, case built” Facility Census: 114 Facility Beds Available: 3 Patient 12 Status: Declined on 2/4/25 at 12:24 a.m. Referral Details: “Alameda county, won’t short doyle” (act that provides funding for hospitalization in specialized mental health facilities) Facility Census: 113 Facility Beds Available: 4 Patient 13 Status: Declined on 2/4/25 at 9:02 p.m. Referral Details: “Pt (patient) is uninsured” “5150 (refers to the California law code for the temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others)” Facility Census: 113 Facility Beds Available: 4 Patient 14 Status: Declined on 2/5/25 at 9:47p.m. Referral Details: “Pt is uninsured” Facility Census: 114 Facility Beds Available: 3 Patient 15 Status: Declined on 2/5/25 at 7:44 p.m. Referral Details: “uninsured per CSW (certified social worker)” Facility Census: 114 Facility Beds Available: 3 Patient 16 Status: Declined on 4/19/25 at 1:39 p.m. Referral Details: “Uninsured” Facility Census: 112 Facility Beds Available: 5 Patient 17 Status: Declined on 4/19/25 at 9:32 a.m. Referral Details: “No bed available at this time” Facility Census: 113 Facility Beds Available: 4 Patient 18 Status: Declined on 4/20/25 at 11:33 a.m. Referral Details: “Patient was declined and dropped” Facility Census: 113 Facility Beds Available: 4 Patient 19 Status: Declined on 4/21/25 at 9:31 a.m. Referral Details: “no available male beds” Facility Census: 111 Facility Beds Available: 6 Patient 20 Status: Declined on 2/2/25 at 8:50 p.m. Referral Details: “Pt’s ALT (alanine transaminase blood test checks the health of your liver) = 155 (H = high)” Facility Census: 112 Facility Beds Available: 5 Patient 21 Status: Declined on 2/4/25 at 7:46 p.m. Referral Details: “patient is conserved” Facility Census: 113 Facility Beds Available: 4 Patient 22: Status: Declined on 2/4/25 at 5:05 a.m. Referral Details: “Pt declined because pt has State III Chronic Kidney Disease (kidneys have moderate damage and aren’t filtering blood as well as they should)” Facility Census: 113 Facility Beds Available: 4 Patient 23 Status: Declined on 2/4/25 10:34 p.m. Referral Details: “Declined for [hospital name]” Facility Census: 113 Facility Beds Available: 4 Patient 24 Status: Declined on 2/5/25 12:06 a.m. Referral Details: “Pt’s ALT = 106 (H)” Facility Census: 114 Facility Beds Available: 3 Patient 25 Status: Declined on 2/5/25 at 8:40 a.m. Referral Details: “Pt not taking his seizure (a sudden burst of electrical activity in the brain) medications. Does not remember his last seizure.” Facility Census: 114 Facility Beds Available: 3 1.During a concurrent interview and record review on 4/22/25 at 9:30 a.m. with ID, “Referral Details (RD)” for Patients 5,12, 13, 14, 15, and 16 were all declined admission to the facility. Patient’s 5 RD dated 1/7/25 indicated, “unfunded,” ID stated, unfunded is no reason to decline a patient. Patient 12’s RD dated 02/04/24 indicated, “ ...County won’t short doyle (act that provides funding for hospitalization in specialized mental health facilities)”. ID stated, the facility probably won’t get paid. Patient 13’s RD dated 2/4/25 indicated, “uninsured,” ID stated, there is no other documentation in record for declining. Patient 14’s RD dated 2/5/25 indicated, “pt. (patient) is uninsured,” ID stated, there is no further documentation for declining. Patient 15’s RD dated 2/5/25 indicated, “uninsured per CSW (certified social worker),” ID stated, no other documentation for declining. Patient 16’s RD dated 4/19/25 indicated, “uninsured,” ID stated only documentation for the decline is uninsured. During a review of the facility’s policy and procedure (P&P) titled, “Admission, Exclusion, Continued Stay and Discharge Criteria,” dated 12/19/2024, the P&P indicated, “It is the policy of [name of hospital] to utilize standardized criteria to guide decisions related to admission ...[name of hospital] does not exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, disability, national origin, or on the basis of age in admission to, participate in, or receipt of services and benefits of any of its programs ...” 2. During an interview on 4/22/25 at 3:00 p.m. with the RMD, the RMD stated all 117 beds are licensed and included for certification by deemed status (meets or exceeds Medicare requirements through an accrediting organization). RMD stated 78 of these 117 beds are available only to a defined group of patients by written contract and the remaining 39 beds are available for community use. During a continued concurrent interview and record review on 4/22/25 at 10:00 a.m. with ID, RD for Patients 6, 9, 17, 18, and 19 were reviewed. Patients 6, 9, 17, 18, and 19 were all declined admission to the facility. Patient 6’s RD dated 4/21/25 indicated, “no male beds.” ID stated there were no community male beds available, would not place a community patient on the contracted bed side. Patient 9’s RD dated 4/21/25 indicated, “no male beds available.” ID stated only contracted beds are available, there were no community male beds. Patient 17’s RD dated 4/19/25 indicated, “no bed available.” ID stated, no beds available on the community side. Patient 18’s RD dated 4/20/25 indicated, “patient was declined and dropped.” ID stated no beds were available on this date on the community side. Patient 19’s RD dated 4/21/25 indicated, “No available male beds.” ID stated there were no community beds available and community patients are not placed in contracted beds. A review of the facility’s document titled “Census By Day Report” (CBDR) dated 4/21/25, the CDBR indicated the total census (all beds in the facility including contracted beds) for 4/19/25 was 113, the total census for 4/20/25 was 113, and the total census for 4/21/25 was 111. The facility capacity is 117 beds. During a review of the facility’s P&P titled, “Admission, Exclusion, continued Stay and Discharge Criteria,” dated 12/19/2024, the P&P indicated, “Capacity: Defined as the ability of the hospital to accommodate an individual examination or treatment of transferred client ...Capability: There is physical space, supplies and staff that can provide the appropriate care within their scope of practice.” 3. During a concurrent interview and record review on 4/22/25 at 10:10 a.m. with ID, the RD’s for Patient’s 1 and 23 were reviewed. Patient 1’s RD dated 2/3/25 indicated, “case built, dropped AIS (an electronic medical record system), declined.” The ID stated, “for some reason we declined ...there should be a reason why we declined.” Patient 23’s RD dated 2/4/25 indicated, “declined for [name of hospital].” The ID stated, there is no explanation for declining patient. The ID further stated [it is] the expectation that the reason for declining patients will be documented on the referral notes. During a review of the facility’s P&P titled, “Assessment and Referral,” dated 12/19/2024, the P&P indicated, “Transfers ... [the facility will] Accept from other hospitals appropriate transfers or individuals requiring the specialized services provided by [name of hospital] and provide those individuals with necessary stabilizing treatment within the hospital’s capabilities.” 4. During a concurrent interview and record review of incoming referrals on 4/22/25 at 11:00 a.m. with the ID, the RD’s for declined Patient’s 2, 3, 4, 7, 8, 10,11, 20, 21, 22, 24 and 25 were reviewed. Patient 2’s RD dated 2/4/25 indicated, “Decline for [name of hospital], patient expressing severe violence.” The ID stated, there should be more documentation and triage of patient by intake staff prior to declining patient. Patient 3’s RD dated 2/5/25 indicated, “62 y/o male with h/o chronic obstructive pulmonary disease (a lung disease characterized by airflow obstruction and breathing difficulties], brought in by ambulance as a code 3 (an emergency vehicles response using lights and sirens; urgent situation requiring immediate action) from a room and board for respiratory distress (difficulty breathing).” The ID stated further information is needed from referring source, patient can be treated at the facility if medically stable and no oxygen is needed. Patient 4’s RD dated 1/6/25 indicated, “patient with AV (arterio vascular) shunt (a vascular access under the skin), used in patients for dialysis (a treatment for patients whose kidneys are not functioning properly).” The ID stated having a dialysis shunt is not a reason to decline the patient, more information should be documented why patient was declined. Patient 7’s RD dated 2/5/25, indicated “Decline for [name of hospital], acute respiratory distress. The ID stated the intake staff should call and get more information such as tests, is the patient on oxygen and discuss with the medical doctor. Patient 8’s RD dated 4/21/25 indicated “incontinent.” The ID stated the facility does not accept patients who are incontinent unless they can change their own briefs ...further information is needed. Patient 9’s RD dated 1/7/25 indicated, “ ...patient has high functioning autism being evicted.” The ID stated, staff should have provided more details ...assess patient status ...nurse to nurse with sending facility and document.” The ID further stated that high functioning autism or being evicted is not reason for declining a patient. Patient 11’s RD dated 2/5/25 indicated, “ingrown toenail, possible infection, refusing treatment ...case built [name of hospital] AIS.” The ID stated an ingrown toenail is not an acceptable reason to decline a patient ...should have been discussed with medical doctor. Patient 20’s RD dated 2/2/25 indicated, “Pt’s (patient’s) ALT (alanine transaminase blood test checks the health of your liver) = 155 (H = high).” The ID stated “unfortunately I don’t have the referral, Registered Nurse (RN) should have called medical doctor. Patient 21’s RD dated 2/4/25 indicated, “patient is conserved.” The ID stated, “This is the only note for declination ...more information is needed”. Patient 22’s RD dated 2/4/25 indicated, “Pt declined because pt has Stage III Chronic Kidney Disease (kidneys have moderate damage and aren’t filtering blood as well as they should).” The ID stated the APH does not accept dialysis patients. The ID reviewed the packet of information sent with referral and stated, “[I] don’t see that this patient is on dialysis”. The ID stated the APH’s medical doctor should have been contacted for further review before declining the patient. Patient 24’s RD dated 2/5/25 indicated, “Pt’s ALT (alanine transaminase blood test checks the health of your liver) = 106 (High)”. The ID stated the intake staff should have contacted the physician for further review. Patient 25’s RD dated 2/5/25 indicated, “Pt not taking his seizure (a sudden burst of electrical activity in the brain) medications. Does not remember his last seizure.” The ID stated there is no other documentation for declining [patient], the APH can administer medications for seizures [if ordered for patient]. During a review of the facility’s P&P titled, “Initial Intake Procedure,” dated 12/19/2024, the P&P indicated, “Prospective patient may arrive to [name of hospital] ...by transfer from emergency rooms, crisis stabilization units, or other referring facilities ...The hospitalist will be consulted if there is a need for additional medical evaluation beyond the medical triage assessment ...the hospitalist will determine is [sic] the patient’s medical needs can be treated at [name of hospital].””