Rainbow Babies and Childrens Hospital

“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: 44810 Based on interview and record review, the facility failed to document communication with a referring facility and failed to keep record of an emergency psychiatric referral for Patient #9 from an outside emergency department. This affected one (Patient #9) of 20 patients reviewed for emergency care. The emergency department census was five. Findings include: Review of the referral for Patient #9 revealed a fax was received from an outside emergency department on 10/06/25 at 11:26 P.M. to the Emergency Psychiatric Assessment Team (EPAT). The referral reported Patient #9 presented to their emergency department after placing a headphone cord around her neck and running into traffic. The information included results of her physical assessment and laboratory (lab) work results obtained by the referring facility. All results were unremarkable. Patient #9 stated she wanted to harm herself to die and was feeling hopeless and like a burden to her family. She scored a high risk on the suicide risk assessment scale. No other documentation was available for Patient #9. Review of information from the referring emergency department revealed Patient #9 came to the free-standing emergency department on 10/06/25. They attempted to have Patient #9 transferred to the facility on 10/07/25 and they spoke with the EPAT Office Manager who reported they had the capacity to accept the patient. The Physician Director of EPAT refused the transfer on 10/07/25 at 8:40 A.M. and did not allow for the emergency department physician to have a physician-to-physician conversation. Interview on 12/02/25 at 1:00 P.M. with Nursing Manager (Staff C) and Director of Pediatric Emergency Room Medicine (Staff D) revealed the EPAT does not operate in their emergency room. Patients are assessed directly in their emergency department and EPAT services are used for the community emergency rooms. Interview on 12/02/25 at 9:07 A.M. with Staff A revealed the EPAT team does not keep a list of their referrals from outside facilities. Telephone interview on 12/03/25 at 10:33 A.M. with Physician Director of EPAT (Staff G), Senior Social Worker EPAT (Staff H), and Senior Social Worker of EPAT (Staff I) revealed they do not keep logs daily of all the referrals they receive. Staff H reported the EPAT Office Manager helps staff by communicating with the referring facilities if the patients are accepted or denied, or if more information is required. Staff G reported she reviewed the referral packet for Patient #9. She reported the referral was denied because more information was required to accept the patient. Staff G reported she just placed the message in the transfer portal but does not have a record of the message given to the referring hospital. The transfer center only keeps patient information for 72 hours. Staff G revealed she would never deny a doctor-to-doctor conversation and was never informed Patient #9’s physician was requesting one. Staff G confirmed they have no way of following up on referrals from outside facilities. They do not keep a log of any referrals they receive. Staff G stated she was unable to provide any documentation about Patient #9, why the referral was not accepted, and who notified the facility. Review of the facility policy titled “Referral and Review of Packets for Out of System Referrals for Patient Admission Emergency Psychiatric Assessment Team,” effective January 2025, revealed EPAT facilitates the admission for patients determined to require inpatient psychiatric care for all University Hospitals emergency departments. EPAT coordinates patient information for referral, insurance is or has already been verified, intake department at targeted entity is contacted to verify bed availability, patient information is faxed for review, upon acceptance ambulance transport is arranged by the sending facility, hand off report is coordinated via EPAT, and all information is documented by EPAT in the transfer center application.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 31597 Based on record review, interview, policy review and review of the manufacturer’s instructions, the faciliy failed to ensure restraints were applied in accordance with manufacturer’s instructions. This affected one (Patient #1) of ten records reviewed. Findings include: Patient #1 was admitted to the facility on 05/06/24 and discharged to jail on 06/14/24. On 06/08/24 at 8:41 PM, Staff K wrote an order for violent restraints and stated in the comments “above the elbow bilaterally to make 6 point restraints”. On 06/12/24 at 7:49 PM, Staff N wrote an order for 6 point restraints. On 06/09/24 at 2:20 PM, Staff O documented Patient #1 had a code violet overnight requiring intramuscular medications. “He was in 6 point restraints”. On 06/12/24 at 7:00 PM, Staff M documented code violet called and Patient #1 was placed in 6 point restraints. On 06/12/24 at 7:30 PM, Staff L documented the team decide to place Patient #1 in 6 point restraints. Additional locking restraints were added to Patient #1’s upper arms. During an interview on 08/19/24 at 3:02 PM, Staff B stated staff have not been trained on how to apply 6 point restraints. During an interview on 08/19/24 at 2:27 PM, Staff B confirmed the manufacturer’s package insert for the locked restraints did not include instructions for applying the restraints above the elbow area. The Posey Twice-As-Tough cuffs - Key Lock Application Instructions revealed to apply the cuffs, wrap the neoprene piece (the blue or red side should be positioned against the skin around the wrist/ankle. It does not state to use above the elbows. Review of the facility policy titled “Use of Restraints and Seclusion”, effective April 2024, stated qualified staff members are those who are trained and able to demonstrate competency in minimizing use of restraints, safe application of restraints, monitoring, and providing care for a patient in restraints. Training takes place as part of orientation and annually thereafter. Of the direct care staff, only registered nurses may perform the assessments necessary of a patient in restraint or seclusion. The training content includes the following: 1. Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of restraints. 2. The use of nonphysical intervention skills. 3. Selecting the least restrictive intervention based on an individualized assessment of the patient’s medical, or behavioral status or condition. 4. The safe application and use of all types of restraint used, includes training in how to recognize and respond to signs of physical and psychological distress, and positional asphyxiation.”