Arbour Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 41143 Based on record review and interview, the Hospital was not in compliance with (Emergency Medical Treatment and Labor Act) EMTALA regulations because the Hospital failed to ensure one Patient (#1), who was accepted as a patient transfer from another Hospital’s Emergency Department, to maintain the Patient’s admission at the Hospital out of a total sample of 30 patients. Patient #1 was admitted to an inpatient unit in the Hospital and was subsequently inappropriately transferred back to the acute care Hospital’s Emergency Department after a few hours on the unit. Findings include: Review of the Hospital’s policy “Assessment and Referral Services, Completion of EMTALA Log”, dated May 2011 indicated the following: -As per EMTALA, the Hospital does not refuse care to anyone who is present on our grounds. -MOT (Memorandum of Transfer) paperwork completed if an EMTALA transfer to Emergency Department. Patient #1 arrived at the Hospital on 4/4/24 around 3:00 P.M. for an admission to an inpatient psychiatric unit. Review of Patient #1’s record indicated prior to the Patient’s transfer from an acute care hospital to the Hospital, information regarding the Patient’s history had been sent to the Hospital on 4/3/24. Patient #1’s documentation from the acute care Hospital indicated the Patient was on probation, in the custody of protective services, had impulsive behaviors, had made homicidal comments towards his/her school principal, and attempted to elope from his/her mother’s vehicle with a knife in order to kill his/her principle. Patient #1 was evaluated by Physician #1 at 3:15 P.M. on 4/4/24 while admitted to the inpatient unit. Patient #1 was assessed by the Admission Registered Nurse (RN) on 4/4/24 at 3:37 P.M.; the Patient told the Admission RN he/she had three open court cases, and the Patient was alert and oriented and cooperative with the admission process. An initial treatment plan was created by the Admission RN. Physician orders were in place for admission to the Hospital as a voluntary admission under section 10 and 11, monitoring, aggression precautions, and medications. Patient #1 was transferred back to the acute care hospital via ambulance and arrived there on 4/4/24 at 6:57 P.M. Further review of Patient #1’s record failed to indicate any documentation regarding transfer back to the acute care hospital’s emergency department, any orders for the transfer, nor any consent for transfer by the Patient’s guardian from the Department of Children and Families (DCF). During an interview with the Assistant Director of Nursing on 4/10/24 at 9:15 A.M., he said Patient #1’s screen from the acute care hospital’s emergency department was reviewed by the Evening RN Supervisor on 4/3/24 and the Patient was accepted for admission to the Hospital. He said Patient #1 arrived at the Hospital on 4/4/24, and on admission the Hospital was made aware of pending criminal cases for the Patient that had not been disclosed prior to transfer of the Patient. He said after the Patient was brought to the inpatient unit, the Physician revoked the section 12B on the Patient and he/she was transferred back to the acute care hospital emergency department. He said normally the Hospital could have cared for Patient #1, however, there was another patient on the inpatient unit who already required a 2:1 at all times secondary to violent and dangerous behaviors; he said having both Patient #1 and the other patient on the unit together could create a dangerous and catastrophic situation for both the patients on the unit and staff working there. He said the Hospital could not provide safe staffing for the unit if Patient #1 had been admitted to the Hospital and allowed to stay. During an interview with Physician #1 on 4/10/24 at 10:00 A.M., he said Patient #1 arrived at the Hospital after threatening his/her principle with a knife and threatening to kill the principle. He said the Hospital had accepted Patient #1 for admission. He said Patient #1 was medically cleared for admission to the Hospital. He said after the during the admission of Patient #1 to the Hospital, it was realized the Patient was similar to another patient on the inpatient unit; he said there would likely be an altercation between Patient #1 and the other patient on the unit. He said he revoked Patient #1’s section 12 after observing the Patient on the unit after his/her admission, spoke with the Chief Medical Officer, and the decision was made to send Patient #1 back to the acute care hospital emergency department for the safety of the Patients and staff on the unit. He said nursing staff reached out to the acute care hospital to notify of the transfer; he did not speak with another physician at the acute care hospital. He said this particular scenario had not happened before at the Hospital, and normally the Hospital could care for Patient #1 if it were not for the other patient with violent behaviors residing on the unit. He said Patient can be transferred to an emergency department from the Hospital under section 21 for medical treatment and stabilization or transfer of a section 12A back to an emergency department because the patient is not medically stable. During an interview with the Chief Medical Officer on 4/10/24 at 10:40 A.M., he said the transfer of Patient #1 back to the acute care Hospital was unfortunate but needed to happen. He said without another violent patient on the inpatient unit the Hospital could have potentially managed Patient #1, however, with another volatile patient on the unit with Patient #1 was dangerous situation. He said Patient #1’s transfer back to the acute care hospital’s emergency department was necessary for everyone’s safety. During an interview with the Admission RN on 4/4/10 at 11:08 A.M., she said Patient #1 had a lack of insight on admission to the Hospital, and a DCF representative was with the Patient as well. She said on admission to the Hospital, Patient #1 denied any suicidal or homicidal ideation, although he/she did admit to wanting to use a pocketknife against his/her principle. She said the general process for accepting and receiving a patient to the Hospital is the transferring hospital sends information over to the Hospital, the Hospital screens the patient referral, if the Hospital accepts the patient for admission the patient is transferred to the Hospital and admitted for treatment. During an interview with the Evening Nursing Supervisor on 4/4/24 at 2:55 P.M., he said he accepted Patient #1 for transfer to the Hospital on 4/3/24 and the Patient was transferred on 4/4/24. He said the Physician decided it was not safe to keep Patient #1 on the unit, so the Patient was transferred back to the acute care hospital. He said he called the emergency department to notify the staff Patient #1 was returning to the acute care hospital. The Hospital failed to ensure Patient #1’s admission was maintained for inpatient psychiatric treatment and stabilization after accepting the Patient’s transfer from an acute care hospital emergency department.”

“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: 41143 Based on record review and interview, the Hospital failed to ensure one Patient (#1), who was accepted as a patient transfer from another Hospital’s Emergency Department, to maintain the Patient’s admission at the Hospital out of a total sample of 30 patients. Patient #1 was admitted to an inpatient unit in the Hospital and was subsequently inappropriately transferred back to the acute care Hospital’s Emergency Department after a few hours on the unit. Findings include: Review of the Hospital’s policy “Assessment and Referral Services, Completion of (Emergency Medical Treatment and Labor Act) EMTALA Log”, dated May 2011 indicated the following: -As per EMTALA, the Hospital does not refuse care to anyone who is present on our grounds. -MOT (Memorandum of Transfer) paperwork completed if an EMTALA transfer to Emergency Department. Patient #1 arrived at the Hospital on 4/4/24 around 3:00 P.M. for an admission to an inpatient psychiatric unit. Review of Patient #1’s record indicated prior to the Patient’s transfer from an acute care hospital to the Hospital, information regarding the Patient’s history had been sent to the Hospital on 4/3/24. Patient #1’s documentation from the acute care Hospital indicated the Patient was on probation, in the custody of protective services, had impulsive behaviors, had made homicidal comments towards his/her school principal, and attempted to elope from his/her mother’s vehicle with a knife in order to kill his/her principle. Patient #1 was evaluated by Physician #1 at 3:15 P.M. on 4/4/24 while admitted to the inpatient unit. Patient #1 was assessed by the Admission Registered Nurse (RN) on 4/4/24 at 3:37 P.M.; the Patient told the Admission RN he/she had three open court cases, and the Patient was alert and oriented and cooperative with the admission process. An initial treatment plan was created by the Admission RN. Physician orders were in place for admission to the Hospital as a voluntary admission under section 10 and 11, monitoring, aggression precautions, and medications. Patient #1 was transferred back to the acute care hospital via ambulance and arrived there on 4/4/24 at 6:57 P.M. Further review of Patient #1’s record failed to indicate any documentation regarding transfer back to the acute care hospital’s emergency department, any orders for the transfer, nor any consent for transfer by the Patient’s guardian from the Department of Children and Families (DCF). During an interview with the Assistant Director of Nursing on 4/10/24 at 9:15 A.M., he said Patient #1’s screen from the acute care hospital’s emergency department was reviewed by the Evening RN Supervisor on 4/3/24 and the Patient was accepted for admission to the Hospital. He said Patient #1 arrived at the Hospital on 4/4/24, and on admission the Hospital was made aware of pending criminal cases for the Patient that had not been disclosed prior to transfer of the Patient. He said after the Patient was brought to the inpatient unit, the Physician revoked the section 12B on the Patient and he/she was transferred back to the acute care hospital emergency department. He said normally the Hospital could have cared for Patient #1, however, there was another patient on the inpatient unit who already required a 2:1 at all times secondary to violent and dangerous behaviors; he said having both Patient #1 and the other patient on the unit together could create a dangerous and catastrophic situation for both the patients on the unit and staff working there. He said the Hospital could not provide safe staffing for the unit if Patient #1 had been admitted to the Hospital and allowed to stay. During an interview with Physician #1 on 4/10/24 at 10:00 A.M., he said Patient #1 arrived at the Hospital after threatening his/her principle with a knife and threatening to kill the principle. He said the Hospital had accepted Patient #1 for admission. He said Patient #1 was medically cleared for admission to the Hospital. He said after the during the admission of Patient #1 to the Hospital, it was realized the Patient was similar to another patient on the inpatient unit; he said there would likely be an altercation between Patient #1 and the other patient on the unit. He said he revoked Patient #1’s section 12 after observing the Patient on the unit after his/her admission, spoke with the Chief Medical Officer, and the decision was made to send Patient #1 back to the acute care hospital emergency department for the safety of the Patients and staff on the unit. He said nursing staff reached out to the acute care hospital to notify of the transfer; he did not speak with another physician at the acute care hospital. He said this particular scenario had not happened before at the Hospital, and normally the Hospital could care for Patient #1 if it were not for the other patient with violent behaviors residing on the unit. He said Patient can be transferred to an emergency department from the Hospital under section 21 for medical treatment and stabilization or transfer of a section 12A back to an emergency department because the patient is not medically stable. During an interview with the Chief Medical Officer on 4/10/24 at 10:40 A.M., he said the transfer of Patient #1 back to the acute care Hospital was unfortunate but needed to happen. He said without another violent patient on the inpatient unit the Hospital could have potentially managed Patient #1, however, with another volatile patient on the unit with Patient #1 was dangerous situation. He said Patient #1’s transfer back to the acute care hospital’s emergency department was necessary for everyone’s safety. During an interview with the Admission RN on 4/4/10 at 11:08 A.M., she said Patient #1 had a lack of insight on admission to the Hospital, and a DCF representative was with the Patient as well. She said on admission to the Hospital, Patient #1 denied any suicidal or homicidal ideation, although he/she did admit to wanting to use a pocketknife against his/her principle. She said the general process for accepting and receiving a patient to the Hospital is the transferring hospital sends information over to the Hospital, the Hospital screens the patient referral, if the Hospital accepts the patient for admission the patient is transferred to the Hospital and admitted for treatment. During an interview with the Evening Nursing Supervisor on 4/4/24 at 2:55 P.M., he said he accepted Patient #1 for transfer to the Hospital on 4/3/24 and the Patient was transferred on 4/4/24. He said the Physician decided it was not safe to keep Patient #1 on the unit, so the Patient was transferred back to the acute care hospital. He said he called the emergency department to notify the staff Patient #1 was returning to the acute care hospital. The Hospital failed to ensure Patient #1’s admission was maintained for inpatient psychiatric treatment and stabilization after accepting the Patient’s transfer from an acute care hospital emergency department.”