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Based on observation, interview, and record review, the hospital failed to comply with the 24 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. This failure had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services.

Findings:

1. The hospital failed to ensure the provision of on-call coverage to provide further evaluation and/or treatment necessary to stabilize an individual with an EMC for two of 21 sampled patients (Patients 1 and 15). Cross reference to A2404.

2. The hospital failed to ensure the MSE was provided in a timely manner to determine whether or not an EMC existed for two of 21 sampled patients (Patients 14 and 16). Cross reference to A2406.

3. The hospital failed to ensure the necessary stabilizing treatment was provided within the capabilities of the hospital for five of 21 sampled patients (Patients 2, 9, 15, 18, and 21). Cross reference to A2407.

4. The hospital failed to ensure the ED staff appropriately transferred the patient from the ED to other hospital. Cross reference to A2409.

5. The hospital (the receiving hospital) failed to ensure the hospital staff properly responded to the calls as per the hospital's P&P when the transferring hospital (Hospital A) requested to transfer the patients to the hospital for two of 21 sampled patients (Patients 1 and 20). Cross reference to A2411.

Based on observation, interview, and record review, the hospital failed to ensure the signage for EMTALA rights with respect to the examination and treatment for EMC and women in labor were posted conspicuously in the ED areas and in L&D department as evidenced by:

* Failure to ensure the EMTALA signage was posted in the ED's triage/treatment areas and ED's trauma treatment area.

* Failure to ensure the EMTALA signage was posted in the L&D department's main entrance.

These failures had the potential to result in the individuals to not be aware of their rights to the examination and treatment in the event of an EMC.

Findings:

Review of the hospital's P&P titled EMTALA - Signage Policy dated March 2023 showed in part:

* To establish guidelines for providing all individuals with the opportunity to be aware of and view their right to medical screening examination and stabilization for an emergency medical condition.

* All Emergency Department and any other place likely to be noticed by all individuals entering the Emergency Department and those individuals waiting for examination and treatment in areas of the hospital other than the traditional Emergency Department such as the entrance area, admitting areas, waiting rooms, and treatment areas located on hospital property must post conspicuously, appropriate signage notifying individuals of their right to an MSE and stabilization or treatment for an EMC and require services for women in labor as specified under EMTALA as well as information indicating whether or not the hospital participates in the Medicaid program.

1. On 11/28/23 at 1044 hours, the hospital's ED was toured with the Quality Review/Process Improvement RN, Interim ED Nursing Director, and Chief Quality and Patient Safety Officer. There was no EMTALA signage posted in the trauma treatment area. In a concurrent interview, the Interim ED Nursing Director acknowledge the findings. The Interim ED Nursing Director also acknowledged there was no EMTALA signage posted in all triage/treatment areas in the ED.

2. On 11/28/23 at 1050 hours, the L&D department was toured with the Quality Review/Process Improvement RN, Nursing Manager of Perinatal Services, and Chief Quality and Patient Safety Officer. When asked, the Nursing Manager of Perinatal Services acknowledged there was no EMTALA signage posted at the main entrance of the L&D department.

Based on interview and record review, the hospital failed to ensure the provision of on-call coverage to provide further evaluation and/or treatment necessary to stabilize an individual with an EMC for two of 21 sampled patients (Patients 1 and 15) as evidenced by:

1. The ED failed to ensure the ED and on-call physicians jointly approved the decision to have a non-physician practitioner respond to the call instead of the on-call physician for Patient 15 as per the hospital's P&P.

2. The ED failed to ensure the direct telephone number of Neurosurgeon 1 was available when the Neurosurgeon 1 was listed as an on-call neurosurgeon as per the hospital's P&P. The ED failed to maintain the ED on-call schedule by including the direct telephone number of the physicians as per the hospital's P&P.

These failures could result in the delay in the stabilizing treatments and substandard health outcomes to the patients.

Findings:

Review of the hospital's P&P titled EMTALA-Definitions and General Requirements dated March 2023 showed the on-call list should be maintained in accordance with the resources available to the hospital and should include the name and the direct telephone number or direct pager of each physician who is required to fulfill on-call duties. A practice group's name, answering service, and general office phone numbers are not acceptable under EMTALA. The purpose of the on-call list is to ensure that the DED is prospectively aware of which physicians, including specialists and sub-specialists, are available to provide treatment necessary to stabilized individuals with EMCs.

1. Review of the hospital's P&P titled EMTALA -Provision of On-Call Coverage dated March 2023 showed the ED physician must be able to first confer with the on-call physician. Midlevel practitioners (usually physician assistants or advanced practice registered nurses) who are employed by and have protocol agreements with the on-call physician, may appear at the hospital and provide further assessment or stabilizing treatment to the individual only after the on-call physician and ED physician confer and the on-call physician so directs the licensed non-physician practitioner to appear at the hospital. The ED physician and the on-call physician must jointly approve the decision to have a non-physician practitioner respond to the call instead of the on-call physician.

On 11/29/23 at 1500 hours, an interview and concurrent review of Patient 15's medical record was conducted with the Quality Review/Process Improvement RN and the Chief Quality and Patient Safety Officer.

Patient 15's medical record showed Patient 15 presented to the ED by EMS on 11/21/23 at 0923 hours, after an unwitnessed fall.

Review of the ED Provider Aware Note dated 11/21/23 at 1051 hours, showed Patient 15 was upgraded to a moderate trauma and care would be transferred to trauma services.

Review of the Neurosurgery NP Note dated 11/21/23 at 1241 hours, showed, "Contacted by Trauma for assessment on acuity of ICH found on CTH today." The Plan section showed, "No neurosurgical intervention is indicated...OK to DC back to care facility..."

Review of the Trauma Report dated 11/21/23, showed it was unknown whether Patient 15 lost consciousness after the unwitnessed fall. The Plan section showed, "A consultation with neurosurgery was obtained while the patient was in the Emergency Room. He stated that the CT scan of the brain showed no acute findings: The patient was therefore transferred back to the rehabilitation center."

In a concurrent interview, the Quality Review/Process Improvement RN stated there was no documentation showing the ED physician and the on-call physician jointly approved the decision to have a non-physician practitioner respond to the call instead of the on-call physician.

The findings were discussed and acknowledged by the Chief Quality and Patient Safety Officer. The Chief Quality and Patient Safety Officer stated the ED had not implemented the provision of on-call coverage P&P.

2. Review of the hospital's P&P titled EMTALA -Provision of On-Call Coverage dated March 2023 showed in part:

* To established guidelines for the hospital and its personnel to be prospectively aware of which physicians, including specialists and sub-specialists, are available to provide additional medical evaluation, and treatment necessary to stabilize individuals with emergency medical condition.

* The Hospital Administrator is responsible to develop an Emergency Department On-Call Schedule via a contractual relationship with the various specialists. Practice group names and general office numbers are not acceptable for contacting the on-call physician. Individual physician names with accurate contact information including the direct telephone number or direct pager where the physician can be reached, are to be put on the on-call list. The hospital MUST be able to contact the on-call physician with the number provided on the list. If the on-call physician decides to list an answering service number as the preferred method of contact, his/her mobile phone number must be provided to the hospital as a backup number to reach the on-call physician.

a. On 11/30/22 at 1258 hours, a tour of the ED was conducted with the Chief Quality and Patient Safety Officer and the Quality Review/Process Improvement RN.

On 11/30/23 at 1304 hours, a concurrent interview and review of the ED on-call schedule dated 11/30/23 was conducted with RN 5. When asked, RN 5 stated the telephone numbers on the on-call schedule were not the direct telephone numbers for the on-call physicians. RN 5 stated the telephone numbers listed on the on-call scheduled were to the physician's office or a "call center."

Ophthalmologist 1 was randomly selected from the ED on-call scheduled and RN 5 called the Ophthalmologist 1's telephone number listed on the ED on-call schedule dated 11/30/23 (7 am to 7 am). RN 5 confirmed the telephone number was not the direct telephone number for Ophthalmologist 1. The telephone number was for Ophthalmologist 1's office, "[Name of Business] Eye Care."

On 11/30/23 at 1312 hours, a concurrent interview and review of the ED on-call schedule dated 11/30/23 was conducted with ED Unit Secretary 2. ED Unit Secretary 2 stated the ED on-call schedule dated 11/30/23 did not list the direct telephone numbers for the on-call physicians. ED Unit Secretary 2 stated the ED on-call schedule was posted throughout the ED and that it was not appropriate for the physician's direct telephone number (e.g., cell phone) to be displayed and for the ED staff to have access to the physician's contact information.

The findings were shared and acknowledged by the Chief Quality and Patient Safety Officer.


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b. Review of the hospital's Transfer Request tracker list for October 2023, showed a request of transfer for Patient 1 as "ER-ER" on 10/17/23; Patient 1 had a diagnosis of stroke.

Review of the Transfer Center notes for Patient 1 dated 10/17/23 showed at 0125 hours, Neurosurgeon 1 was called by a Transfer Center staff for a physician-to-physician communication; however, there was no answer from the physician. The documentation showed the telephone number was not the direct telephone number of Neurosurgeon 1.

Review of the hospital's ED Call Schedule - Neurosurgery for October 2023, showed Neurosurgeon 1 was listed on the ED Call Schedule as an on-call physician on 10/16 to 10/20/23. The telephone number shown on the ED Call Schedule - Neurosurgery was the same telephone number as described on the transfer center's documentation.

On 11/29/23 at 1103 hours, an interview and concurrent record review was conducted with the Chief Quality and Patient Safety Officer. The Chief Quality and Patient Safety Officer acknowledged the above findings. The Chief Quality and Patient Safety Officer verified the telephone number of Neurosurgeon 1 as shown on the on-call schedule list was not the direct telephone number of Neurosurgeon 1. The Chief Quality and Patient Safety Officer acknowledged the telephone number was the physician's office number during business hours, and after business hours, the number would be transferred over to an answering service company.

Based on interview and record review, the hospital failed to ensure the Emergency Department Logs and the L&D Central Logs were accurately maintained. This failure had the potential to result in the hospital not being able to accurately track the care provided to the individuals who presented to the ED and L&D department for the treatments of their emergency medical conditions.

Findings:

Review of the hospital's P&P titled EMTALA - Central Log Policy dated March 2023 showed in part:

* The hospital must maintain the Central Log in an electronic or paper format.

* The logs must contain at a minimum, the name of the individual; the date, time and means of the individual's arrival; the individual's age; the individual's sex; the individual's record number; the nature of the individual's complaint; the individual's disposition; the individual's time of departure; and whether the individual: refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged or expired.

1.a. Review of the hospital's Emergency Department Logs for June and October 2023 showed the Emergency Department Logs were not completed in its entirety as the mode of arrival, chief complaint, and disposition were not documented in the Emergency Department Logs for two sampled patients (Patients 4 and 5) and two nonsampled patients (Patients 22 and 23).

On 11/29/23 at 1445 hours, an interview and concurrent record review was conducted with the Chief Quality and Patient Safety Officer. The Chief Quality and Patient Safety Officer verified the Emergency Department Logs were not completed in its entirety. In addition, the Chief Quality and Patient Safety Officer verified there were patients included in the log but did not come to the hospital's ED as patients.


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b. On 11/27/23, a random review of the Emergency Department Logs for September and November 2023 showed the Emergency Department Logs were not completed in its entirety as the mode of arrival, chief complaint, and disposition were not documented in the Emergency Department Logs for at least 12 patients for November 2023 and at least 15 patients for September 2023.

On 11/28/23 at 1410 hours, during an interview with the Chief Quality and Patient Safety Officer, the Chief Quality and Patient Safety Officer acknowledged the findings and confirmed the Emergency Department Logs had not been maintained.

c. On 11/30/23 at 1100 hours, an interview and concurrent review of the Emergency Department Log for November 2023 and Patient 19's medical record was conducted with the Quality Review/Process Improvement RN.

Patient 19's medical record showed Patient 19 presented to the ED by EMS on 11/19/23 at 2232 hours, after a motor vehicle accident.

Review of the ED Provider Aware Note dated 11/20/23 at 0101 hours, showed Patient 19 was to be admitted inpatient to ICU. The Disposition section showed the patient left against medical advice.

In a subsequent record review, the Quality Review/Process Improvement RN stated Patient 19 had not left AMA; the patient was admitted to the ICU and then discharged home.

Review of the Emergency Department Log for November 2023 showed the Disposition section showed Patient 19 had left the ED AMA.

The findings were discussed and acknowledged by the Quality Review/Process Improvement RN. The Quality Review/Process Improvement RN stated the ED Disposition was incorrect. The Disposition should have been documented as admitted and should not be documented as AMA.

2.a. On 11/27/23, a random review of the L&D Central Logs for June, July, August, September, October, and November 2023 showed the L&D Central Logs were not completed in its entirety. The time of arrival, means of arrival, disposition or discharge time was not always documented. For example, at least 15 patients had no disposition documented in the logs from June through November 2023.

On 11/28/23 at 1100 hours, during an interview and concurrent review of the L&D Central Log with the Chief Quality and Patient Safety Officer, the Chief Quality and Patient Safety Officer acknowledged the L&D Central Logs had not been maintained.

b. On 11/27/23 at 1056 hours, an interview and concurrent review of the L&D Central Log for October 2023 was conducted with the Quality Review/Process Improvement RN and the Nursing Manager of Perinatal Services.

Review of the log entry for Patient 14 dated 10/30/23, showed the time of arrival was 0406 hours; there was no documentation of the departure time or of the patient's disposition. In addition, the log entry had been crossed off. When asked, the Nursing Manager of Perinatal Services stated the log entry for Patient 14 had been cross off because the patient had arrived in active labor and delivered quickly; the L&D nurses had not conducted the MSE; the MSE was conducted by the physician.

On 11/29/23 at 1416 hours, an interview and concurrent review of Patient 14's medical record was conducted with the Quality Review/Process Improvement RN and the Chief Quality and Patient Safety Officer.

Patient 14's medical record showed Patient 14 presented to the ED on 10/30/23 at 0359 hours with contractions and was immediately transported to L&D.

Review of the L&D nursing documentation dated 10/20/23 at 0410 hours through 04040 hours showed, "Notified [name of physician] ...about patient's complain, fetal tracing...Received admission orders."

The findings were discussed and acknowledged by the Chief Quality and Patient Safety Officer. The Chief Quality and Patient Safety Officer stated the log entry should have been completed in its entirety and the entry should not have been crossed off.

Based on interview and record review, the hospital failed to ensure the MSE was provided in a timely manner to determine whether or not an EMC existed for two of 21 sampled patients (Patients 14 and 16) as evidenced by:

1. For Patient 16, the ED staff did not implement the P&P for EMTALA general requirements when the patient was observed leaving the ED without having an MSE.

2. For Patient 14, the ED staff did not implement the P&P for triage of pregnant patient.

These failures had the potential to result in poor clinical outcomes and serious adverse events to the patients receiving the ED services.

Findings:

1. Review of the hospital's P&P titled EMTALA - Definitions and General Requirements dated March 2023 showed in part:

* Leaving DED after Triage but before an MSE. If an individual presents to the DED and requests services for a medical condition, is triaged and then indicates a desire to leave prior to the MSE (LWBS), the facility should use its best efforts to:

- Offer the individual further medical examination and treatment as may be required to identify and stabilize an EMC.

- Discuss with the individual the risks and benefits involved in leaving prior to the medical screening and document
same.

- Ask the patient to sign the Refusal to Permit Medical Treatment Form.

- If the individual refuses to sign the Refusal to Permit Medical Treatment Form, hospital personnel should document that the Refusal to Permit Medical Treatment Form was provided, and the individual refused to sign the form.

- Document the individual's waiver of his or her right to MSE, or the attempts to locate the individual if he or she left
without notifying someone

- Describe, in the medical record, the examination and treatment that was refused or the request for treatment was
withdrawn; and

- Sign the form, adding date and time.

On 11/29/23 at 1449 hours, an interview and concurrent review of Patient 16's medical record was conducted with the Quality Review/Process Improvement RN and the Chief Quality and Patient Safety Officer.

Patient 16's medical record showed the patient presented to the ED on 9/3/23 at 1427 hours, for shortness of breath.

Review of the ED Triage Aware Note dated 9/3/23 at 1443 hours, showed Patient 16 complained of feeling SOB in the morning and did not have her inhaler. The patient's ESI acuity level was four.

Review of the Progress Note signed by the PA on 9/3/23 at 1507 hours, showed, "I was informed by the front desk that patient was seen leaving the emergency department. Patient had left without being seen."

When asked, the Quality Review/Process Improvement RN stated there was no documentation an MSE was conducted for Patient 16. The Quality Review/Process Improvement RN confirmed there was no documentation the ED staff implemented the hospital's P&P for a patient that left the ED without an MSE.

The findings were shared and acknowledged by the Chief Quality and Patient Safety Officer.

2. Review of the hospital's P&P titled Labor Patients, Observation dated August 2021 showed in part:

* Purpose: To provide appropriate maternal/fetal evaluation and assessment.

* Patients presenting with pregnancy related complaints or signs of active labor will be assessed and triaged in the ED by a triage RN and/or ED Physician/Physician Assistant.

On 11/29/23 at 1416 hours, an interview and concurrent review of Patient 14's medical record was conducted with the Quality Review/Process Improvement RN and the Chief Quality and Patient Safety Officer.

Patient 14's medical record showed Patient 14 presented to the ED on 10/30/23 at 0353 hours with contractions. The patient was 40 weeks pregnant.

The Quality Review/Process Improvement RN confirmed there was no documentation a completed triage assessment was conducted in the ED for Patient 14 as per the hospital's P&P.

On 11/30/23 at 1041 hours, during an interview with the Interim ED Nursing Director, the Interim ED Nursing Director confirmed the hospital's form titled ED to L&D Quick Triage Form, which was the triage assessment by the ED Triage RN, was not found in Patient 14's medical record.

The findings were shared and acknowledged by the Chief Quality and Patient Safety Officer.

Based on observation, interview, and record review, the hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for five of 21 sampled patients (Patients 2, 9, 15, 18, and 21) and failed to ensure the ED equipment was available and properly maintained as evidenced by:

1. For Patient 15, the trauma physician failed to document Patient 15's emergency medical condition had been stabilized before discharging the patient.

2. For Patient 21, the hospital failed to ensure the AMA P&P was implemented for the patient.

3. For Patients 2 and 18, the ED staff failed to conduct a thorough contraband search for Patients 2 and 18 as per the hospital's P&P. In addition, the ED staff failed to complete the Close Observation Flowsheet for Patient 18 which consisted of documenting the patient's location and the patient's behavior every 15 minutes.

4. For Patient 9, the ED staff did not conduct the pain reassessment after administering the pain medication to the patient as per the hospital's P&P.

5. The hospital did not ensure the ED pediatric crash cart were maintained as per the hospital's P&P for the patient use in the emergent event. In addition, the L&D staff failed to ensure the adult crash cart was stored in a location where it would be always readily available and accessible.

6. The hospital staff failed to ensure the last maintenance date was posted on the HEPA filter in the patient care area, failed to inspect and maintain the overhead exam lights used in the patient care areas in the ED, and failed to ensure the call lights in the ED patient restrooms provided with safety measures for vulnerable patients.

These failures had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services.

Findings:

Review of the hospital's P&P titled EMTALA - Definitions and General Requirement dated March 2023 showed EMTALA requires the hospital to do the following:

* If the hospital determines that an individual does have an EMC, provide necessary stabilizing treatment to the individual or provide for an appropriate transfer.

1. On 11/29/23 at 1500 hours, an interview and concurrent review of Patient 15's medical record was conducted with the Quality Review/Process Improvement RN and Chief Quality and Patient Safety Officer.

Patient 15's medical record showed Patient 15 presented to the ED by EMS on 11/21/23 at 0923 hours, after an unwitnessed fall.

Review of the ED Provider Aware Note dated 11/21/23 at 1051 hours, showed Patient 15 would be upgraded to a moderate trauma and care and transferred to trauma services.

Review of the Neurosurgery NP Note dated 11/21/23 at 1241 hours, showed "Contacted by Trauma for assessment on acuity of ICH found on CTH today." The Plan section showed, "No neurosurgical intervention is indicated...OK to DC back to care facility."

Review of the Trauma Report dictated on 11/21/23 at 2106 hours, showed dated 11/21/23, showed it was unknown whether Patient 15 lost consciousness after the unwitnessed fall. The Plan section showed, "A consultation with neurosurgery was obtained while the patient was in the Emergency Room. He stated that the CT scan of the brain showed no acute findings: The patient was therefore transferred back to the rehabilitation center."

In a concurrent interview, the Quality Review/Process Improvement RN stated there was no documentation showing Patient 15's medical condition had been stabilized and the patient could be discharged from the hospital.

The findings were discussed and acknowledged by the Chief Quality and Patient Safety Officer.

2. Review of the hospital's P&P titled Against Medical Advice, Leaving dated February 2022 showed in part:

* Before a patient is discharged prior to the completion of treatment or contrary to medical advice, the patient's physician must first attempt to provide the patient or legal representative with information regarding why continued hospitalization is recommended, the potential consequences of leaving, the benefits of continued hospitalization and any alternatives such as transfer to another facility or outpatient treatment for the patient can make an informed decision on whether or not to leave the hospital.

* If the physician is not available to speak with the patient in person, the physician may provide the informed consent on leaving against medical advice by telephone. The nurse shall document in the progress notes date, time, and a notation that the physician spoke with the patient via phone to provide informed consent. The physician dictates in the discharge summary that he provided the informed consent.

On 11/29/23 at 1121 hours, an interview and concurrent review of Patient 21's medical record was conducted with the Quality Review/Process Improvement RN and the Nursing Manager of Perinatal Services.

Patient 21's medical record showed Patient 21 presented to the ED on 11/24/23 at 1803 hours, with a chief complaint of hypertension. The patient's EGA was 38 weeks and five days.

Review of the ED Triage Aware Note dated 11/24/23 at 1828 hours, showed Patient 21 was triaged at 1818 hours. The patient's ESI level was two.

Review of the L&D nursing documentation dated 11/24/3 at 1900 hours, showed Patient 21 was referred to the hospital to rule out pre-eclampsia. Physician 3 was notified of the patient's status and ordered laboratory tests.

Further review of the L&D nursing documentation dated 11/24/23, showed the following:

* At 1920 hours, Patient 21 refused laboratory tests.

* At 1933 hours, "Informed [name of the physician] regarding pt's refusal for labs and pt willing to be discharged by AMA. MD stated she did not want to speak with pt via the telephone. No new orders received."

Review of the Nursing Discharge Summary dated 11/24/23 at 2027 hours, showed Patient 21 left AMA on 11/24/23 at 1948 hours.

In a concurrent interview, the Nursing Manager of Perinatal Services confirmed Physician 3 did not implement the AMA P&P for Patient 21.

3. Review of the hospital's P&P titled Suicide Patient, Assessment and Care Of dated November 2022 showed the following:

* The purpose is to identify patients at risk for suicide and to assure that their immediate safety needs are met in the most appropriate care setting within the scope of services provided by the organization.

* Patients with a diagnosis/admission complaint of, purposeful overdose, current attempt to harm self/suicide, or suicidal ideation with concrete plan will be considered HIGH RISK. Any patient identified as an active high risk for suicide will be placed on suicide precautions.

* In the ED:

- The patient is in continuous observation.

- Assess patient room and remove any items with potential for self-harm; utilize the Suicide Safety Checklist Form, which will be a part of the patient's permanent medical record and utilize the "Contraband List" as a guide of items to remove from patient room.

Review of the Contraband List showed the contraband items which are not allowed in the patient care areas, include pins of any kind, glass objects, shoelaces and clothing with strings, metal items, or sharp items.

a. On 11/29/23 at 1525 hours, an interview and concurrent review of Patient 18's medical record was conducted with the Quality Review/Process Improvement RN and the Interim ED Nursing Director.

Patient 18's medial record showed Patient 18 presented to the ED on 11/10/23 at 1325 hours, with suicidal thoughts. The patient was transferred to other facility on 11/11/23 at 1000 hours.

Review of the ED Triage Aware Note dated 11/10/23 at 1343 hours, showed "Pt placed on 5150 DTS." Patient 18 was identified as "HIGH RISK for suicide. Needs 1:1 monitoring."

Review of the ED Provider Aware Note dated 11/10/23 at 1347 hours showed, "Patient's work-up reveals significant alcohol intoxication...patient will be watched." The Impression section showed "Suicidal Ideation/5150."

Review of the Suicide Safety Checklist dated 11/10/23 at 1508 hours, showed the box of "1:1 Observer to keep the patient In Line of Sight at All Time" was checked.

* Review of the Close Observation Flowsheet did not show documentation Patient 18's locations and the patient's behaviors were observed every 15 minutes on 11/10/23 from 2315 hours through 11/11/23 at 0700 hours.

The findings were shared and acknowledged by the Quality Review/Process Improvement RN.

* When asked about the contraband search, the Interim ED Nursing Director confirmed there was no documentation showing a contraband search was conducted for Patient 18.

b. Review of Patient 2's medical record showed the patient came to the ED on 6/26/23.

Review of the ED Triage Aware Note dated 6/26/23 at 2102 hours, showed Patient 2's chief complaint was overdose. Patient 2 reported the patient intended to harm self. A suicide screening was conducted for Patient 2 and the patient was identified as high risk for suicide.

On 11/29/23 at 1408 hours, an interview and concurrent record review of Patient 2's medical record was conducted with the Clinical Educator. The above documentation on Patient 2's medical record was acknowledged by the Clinical Educator.

On 11/30/23 at 1421 hours, an interview was conducted with the Chief Quality and Patient Safety Officer, the Interim ED Nursing Director, the Nursing Manager of Perinatal Services, and the Quality Review/Process Improvement RN. The Chief Quality and Patient Safety Officer and Interim ED Nursing Director acknowledged there was no documentation to show if Patient 2's room was assessed and removed any items with potential for self-harm by utilizing the contraband list as per the hospital's P&P.


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4. Review of the hospital' P&P titled Pain Management dated March 2021 showed in part:

* Purpose: to assure that patients receive an assessment and management of their pain consistent with the scope of care, treatment, and service provided by the organization in its various care settings. The goal is to keep the pain level of every patient at three or less.

* Emergency Department

- Initial Assessments: Patient seen in the ED shall receive a screen during the triage or initial assessment process to identify the presence pain. If the screen is positive, then the patient shall receive an assessment to gather sufficient information to identify the pain. The information that may be obtained during this assessment includes, but is not limited to: the intensity of pain using age or condition appropriate assessment tools; the location and nature of pain; and the patient's tolerance to pain and acceptable intensity of pain (pain goal).

- Reassessment Following Treatment of Pain: If a treatment intervention for pain is provided, then the response to that intervention must be assessed. Reassessment is recommended to occur within 15-60 minutes following treatment (depending on the type of intervention).

On 11/28/23 1100 hours, Patient 9's medical record was reviewed with the Quality Review/Process Improvement RN.

Patient 9's medical record showed Patient 9 arrived to the hospital ED via paramedic on 8/2/23 at 0902 hours, with the chief complaint of burns on his face and arms.

Review of the ED Triage Aware Note showed Patient 9 was triaged on 8/2/23 at 0908 hours. The patient's pain level was seven out of 10.

Review of Patient 9's MAR (Medication Administration Record) showed Dilaudid (a pain medication) 1 mg IV was administered to the patient on 8/2/23 at 0908 hours. Another dose of Dilaudid 1 mg IV was administered to the patient on 8/2/23 at 0933 hours.

Review of the Pain Assessment flowsheets showed there was no documented evidence showing the ED staff reassessed Patient 9 for pain after the patient was receiving IV pain medication on 8/2/23 at 0908 and 0933 hours.

On 11/28/23 at 1330 hours, an interview and concurrent review of Patient 9's medical record was conducted with the Interim ED Nursing Director. The Interim ED Nursing Director confirmed the findings.

5. Review of the hospital's P&P titled Equipment Check dated June 2021 showed the purpose is to maintain ED equipment that is functional and adequately stocked. Department equipment is checked and stocked every shift:

- Crash carts (adult and pediatric)

- Defibrillators: ED RN signatures are placed on the crash cart checklist indicating that the defibrillators were checked and are in functional order.

Review of the hospital's P&P titled Crash Carts dated July 2020 showed the contents of each crash cart including the supplies and medications, will be listed and available for reference in each crash cart. Crash carts are inspected daily by the nursing staff in each patient care area where crash carts are located.

a. On 11/27/23 at 0800 hours, a tour of the ED patient care areas was conducted with the Infection Control Manager, Trauma Service Manager, and RN 3. The ED's pediatric crash cart did not have a defibrillator and the pediatric crash cart checklist for monitoring and checking the crash cart supplies or testing of a defibrillator as per the hospital's P&P.

When asked if there should be a defibrillator on every crash cart, RN 3 stated they had defibrillators in the other areas of the ED. RN 3 stated the pediatric defibrillation pad could be able to hook up to the adult defibrillator. When asked about the daily crash cart check list for checking the defibrillator, supplies, and medications, the Trauma Service Manager and RN 3 stated it was part of all the ED staff's responsibility to check the crash carts daily and sign off. When asked to view the pediatric crash cart check list, the Trauma Service Manager stated the nurses probably just used the adult crash cart check list. When asked, the Trauma Service Manager and RN 3 was unable to show documented evidence the daily check list for the pediatric crash cart was completed for the ED pediatric crash cart.

On 11/28/23 at 0915 hours, an interview was conducted with the Chief Quality and Patient Safety Officer about the pediatric crash cart not having a defibrillator and no having crash cart checklist. The Chief Quality and Patient Safety Officer confirmed the above findings and stated every crash cart including the pediatric crash cart, should have its own defibrillator and daily crash cart checklist.

b. On 11/28/23 at 1050 hours, a tour of the L&D department was conducted with the Chief Quality and Patient Safety Officer, the Quality Review/Process Improvement RN, and the Nursing Manager of Perinatal Services.

During a concurrent interview, Nursing Manager of Perinatal Services confirmed the L&D department had only one adult crash cart and it was stored in the PACU which was locked with keypad access only.

The findings were acknowledged by the Nursing Manager of Perinatal Services.

6. On 11/27/23 at 0800 hours, a tour of the ED patient care areas was conducted with the Infection Control Manager and Trauma Service Manager, and RN 3. The following was identified:

a. A HEPA Filter machine in one of the ED's patient bays was not labeled with the last maintenance date.

When asked what the equipment was being used for, the Infection Control Manager stated it was used for patients who needed isolation precautions. When asked when the last maintenance date was and if the equipment was functional, the Trauma Service Manager had to call and verify with the facilities department. The facilities staff informed the Infection Control Manager the machine was still operational and could be used whenever needed. When asked how often the equipment would be checked for maintenance, the Infection Control Manager and Chief Quality and Patient Safety Officer stated equipment would be checked and maintained on an annual basis and should be posted on the equipment.

b. The ED's patient care area showed the overhead exam lights did not have dates posted to show when their last maintenance was done. When asked when the last maintenance was done for the overhead electric lights that were positioned over the beds of the patients, the Chief Quality and Patient Safety Officer stated they had never been done until she mentioned it and after it was brought to her attention.

c. The patients' restrooms showed the cords of the call light was not long enough for the patients who could be at risk of potential fall patients. When asked about the short cord attached to the call light system, the Infection Control Manager stated it was probably short like that to keep patients from using it as a ligature. When asked about vulnerable patients who might experience a fall, the Infection Control Manager stated she was unaware of the breakaway cords that could assist the patients who might experience a fall while in the restroom as well as provide a safety measure for suicidal patients at risk.

On 11/28/23 at 0915 hours, an interview was conducted with the Chief Quality and Patient Safety Officer about the overhead exam lights and the call lights in the patient's restrooms for safety measures. The Chief Quality and Patient Safety Officer confirmed the above findings. The Chief Quality and Patient Safety Officer also confirmed the exam lights were not being monitored every year by the facilities department as they should be, especially, since one of the overhead exam lights needed a bulb replacement.

Based on interview and record review, the hospital failed to ensure the ED staff appropriately transferred the patient from the ED to other hospital as evidenced by:

1. The hospital failed to ensure the ED and the L&D department utilized the approved Transfer Summary and Certification Form and the Patient's Request/Refusal/Consent to Transfer Form.

2. The hospital failed to ensure the ED contracted services were evaluated annually.

3. The ED staff did not accurately complete the ED Interfacility Patient Transfer Acknowledgement & Consent form for one of 21 sampled patients (Patient 7).

These failures had the potential to result in poor clinical outcomes and serious adverse event to the patients receiving ED services.

Findings:

1. On 11/28/23 at 1014 hours, an interview and concurrent review of the hospital's P&P titled EMTALA - Transfer Policy dated March 2023 was conducted with the Chief Quality and Patient Safety Officer. The Chief Quality and Patient Safety confirmed the ED and the L&D department were not utilizing the approved Transfer Summary and Certification Form and the Patient's Request/Refusal/Consent to Transfer Form; and the ED was utilizing the form titled ED Interfacility Patient Transfer Acknowledgement & Consent.

On 11/28/23 at 1100 hours, a tour of the L&D department was conducted with the Chief Quality and Patient Safety Officer and the Nursing Manager of Perinatal Services. When asked about the Transfer Summary and Certification form, the Nursing Manager of Perinatal Services stated the forms were not maintained in the L&D department.

On 11/28/23 at 1117 hours, during an interview with RN 6, RN 6 stated that it was rare for an L&D patient to be transferred out and RN 6 was not sure which form had to be completed if a patient had to be transferred to HLOC.

The Chief Quality and Patient Safety Officer acknowledged the findings.

2. On 11/28/23, a review of the list of ED contract services agreements was conducted. The list of agreements included but was not limited to ambulance services, transfer to HLOC, telehealth services, ED physicians, and physicians on-call.

On 11/30/23 at 1430 hours, the Chief Quality and Patient Safety Officer was interviewed and stated the ED contract services agreements should have been evaluated yearly but were not.


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3. On 11/29/23 at 0900 hours, an interview and concurrent review of Patient 7's medical record was conducted with the Quality Review/Process Improvement RN and the Interim ED Nursing Director.

Patient 7's medical record showed Patient 7 came to the ED on 7/1/23 at 0857 hours, for stroke symptoms and was transferred to other hospital on 7/1/23 at 1329 hours.

Review of the ED Provider Aware Note dated 7/1/23 at 0902 hours, showed the ED physician spoke with a physician who would accept Patient 7 for transferring for further stroke work-up.

Review of the ED Interfacility Patient Transfer Acknowledgement & Consent form signed by the ED physician on 7/1/23 at 1213 hours, showed Patient 7 was transferred for further medical care. The form showed the accepting physician's name was not the same as the name the ED physician had spoken to and referred to as the accepting physician.

When asked, the Interim ED Nursing Director acknowledged the accepting physician's name on the ED Interfacility Patient Transfer Acknowledgement & Consent form was incorrect and should have been the same physician's name who the ED physician had spoken to.

The Interim ED Nursing Director confirmed the findings.

Based on interview and record review, the hospital failed to ensure Hospital B's staff (Hospital B was the receiving hospital) properly responded to the calls as per Hospital B's P&P when the transferring hospital (Hospital A) requested to transfer the patients to Hospital B for two of 21 sampled patients (Patients 1 and 20) as evidenced by:

1. For Patient 1, Neurologist 1 did not respond to the call as per the hospital's Medical Staff General Rules and Regulations.

2. For Patient 20, Neurologist 1 requested not to connect the call with Hospital A's ED physician. The ED staff did not direct the call to Hospital B's ED physician when Hospital A's ED physician requested to transfer Patient 20 to Hospital B via the transfer center. Hospital B's admitting staff informed the Transfer Center that an insurance authorization was required for Patient 20's transfer into Hospital B.

These failures had the potential to result in poor clinical outcomes and serious adverse event to the patients receiving ED services in the hospital.

Findings:

Review of the hospital's P&P titled EMTALA-Transfer Policy dated March 2023 showed a hospital with specialized capabilities or facilities shall accept from a transferring hospital an appropriate transfer of an individual with an EMC who requires specialized capabilities if the receiving hospital has the capacity to treat the individual. The transfer of an individual shall not consider an individual's insurance status and ability to pay for medical services. Hospitals may utilize a Transfer Center to facilitate the transfer of any individual from or to the ED of the transferring facility to the receiving facility. At the ED physician's request, the Transfer Center must facilitate a discussion between the ED Physician and the on-call physician of the receiving facility. The on-call physician does not have authority to refuse an appropriate transfer on behalf of the facility.

Review of hospital's P&P titled Transfer of Patient from an Outside Facility to the ED dated June 2021 showed the transfer will be arranged by direct and appropriate physician-to-physician conversation. For the documentation about the transfer, the EMTALA Transfer Acceptance or Denial Form must be completed by the ED Charge RN or Trauma Clinician or nurse designee.

Review of the hospital's Medical Staff General Rules and Regulations effective on 8/23/21, showed the primary objective of a "hand off" is to provide accurate information about a patient's care, treatment, current condition, and any recent or anticipated changes. The information communicated during a hand off must be accurate. Circumstances requiring Physician-to-Physician hand-off communication include, but are not limited to request for consultation, admissions facilitated by the Emergency Department, or transfer of patient from the ED to another healthcare facility. Medical staff and allied health professional members should respond to pages and telephone messages within thirty (30) minutes.

1. Review of Patient 1's Transfer Center notes dated 10/17/23, showed the following:

- At 0116 hours, the Transfer Center received a call from Hospital A's RN who stated Hospital A had a patient with an ischemic stroke.

- At 0143 hours, the Transfer Center staff reported to Neurosurgeon 1 about Patient 1. Neurosurgeon 1 stated the patient needed a neurologist.

- At 0145 hours, voicemail message was left to Neurologist 1.

- At 0147 hours, the Transfer Center staff placed a call to the Transfer Center Manager and informed the Transfer Center Manager about Patient 1. The Transfer Center staff contacted Hospital B's House Supervisor to verify the telephone number of Neurologist 1. Hospital B's House Supervisor stated Hospital B's House Supervisor would send a text message to Neurologist 1.

Further review of the Transfer Center note did not show Neurologist 1 called back the Transfer Center.

Review of Hospital B's ED Call Schedule - Neurology for October 2023, showed Neurologist 1 was the on-call physician on 10/16 and 10/17/23. The telephone number of Neurologist 1 shown on the Hospital B's ED Call Schedule - Neurology was the same telephone number documented in the transfer center notes for Patient 1.

On 11/29/23 at 1103 hours, an interview and concurrent record review was conducted with the Chief Quality and Patient Safety Officer. The Chief Quality and Patient Safety Officer verified there was no documentation to show Neurologist 1 called back the Transfer Center.

2. Review of Hospital B's ED Call Schedule - Neurology for October 2023, showed Neurologist 1 was the on-call physician on 10/16 and 10/17/23.

Review of Patient 20's medical record showed the patient came to Hospital B's ED from Hospital A on 10/16/23 at 1721 hours.

Review of the ED Triage Aware Note dated 10/16/23 at 1730 hours, showed Patient 20 was triaged on 10/16/23 at 1722 hours. The patient's chief complaint was stroke symptoms.

Review of Patient 20's EMTALA Transfer Acceptance or Denial form dated 10/16/23 at 1430 hours, showed the following:

- Patient 20 had a diagnosis of stroke.

- The CT scan result was "likely ischemic."

- The patient was unstable and required a higher level of care.

- The ED staff requested to page Neurologist 1 so Neurologist 1 could discuss with the ED physician; however, "unsure why" Neurologist 1 refused the physician-to-physician communication with the ED physician.

a. Review of the Transfer Center notes for Patient 20 dated 10/16/23, showed the following:

- Per Hospital A's ED physician, Patient 20's stroke was likely ischemic and emergent.

- Transfer Center staff contacted Neurologist 1 and the staff presented about Patient 20's case.

- Transfer Center staff requested Neurologist 1 if the staff could connect the call to Hospital A's ED physician. However, Neurologist 1 requested not to connect the call to Hospital's A ED physician and stated the patient just needed to be sent over ASAP.

On 11/29/23 at 1103 hours, an interview and concurrent record review was conducted with the Chief Quality and Patient Safety Officer. The Chief Quality and Patient Safety Officer verified the transfer center documentation for Patient 20. The Chief Quality and Patient Safety Officer stated Neurologist 1 should had spoken to the Hospital A's ED physician.

On 11/30/23 at 1255 hours, an interview and concurrent record review was conducted with the Interim ED Nursing Director. The Interim ED Nursing Director verified the EMTALA Transfer Acceptance or Denial form for Patient 20. The Interim ED Nursing Director acknowledged, according to the transfer form Neurologist 1 refused to speak to Hospital A's ED physician.

b. Review of ED Staff 1's job description modified on 3/16/21, showed the staff will accept and relay other communications, answers phone timely and directs call appropriately.

Review of the Transfer Center notes for Patient 20 dated 10/16/23, showed at 1423 hours, the Transfer Center staff received a call from Hospital A's ED staff about Patient 20 who had a stroke. The Transfer Center staff contacted the Hospital B's ED and informed ED Staff 1 that Neurologist 1 advised to send Patient 20 emergently to Hospital B's ED. ED Staff 1 informed the Transfer Center staff that Neurologist 1 needed to call Hospital B's ED physician. The Transfer Center staff informed ED Staff 1 that Hospital A's ED Physician was on the other telephone line and requested to connect with Hospital B's ED physician; however, ED Staff 1 informed the Transfer Center staff to have Neurologist 1 to call Hospital B's ED physician first.

On 11/29/23 at 0935 hours, an interview was conducted with ED Staff 1. ED Staff 1 was asked to describe the process when receiving a call from the Transfer Center. ED Staff 1 stated when the ED Staff received a call from the Transfer Center, the ED Staff would ask the type of transfer from the Transfer Center. ED Staff 1 stated for example, if the transfer was related to a stroke, the ED staff would transfer the call to the ED charge nurse.

On 11/29/23 at 0940 hours, an interview was conducted with RN 4. RN 4 acknowledged the process related to receiving a call from the Transfer Center as described above. RN 4 stated the RN would take the information provided by the Transfer Center staff and would inform the ED physician about the call from the Transfer Center.

On 11/29/23 at 1103 hours, an interview and concurrent record review was conducted with the Chief Quality and Patient Safety Officer. The Chief Quality and Patient Safety Officer verified the above findings. The Chief Quality and Patient Safety Officer acknowledged the ED Staff should had the Transfer Center staff connected the telephone call of the transferring ED physician to the receiving ED physician.

On 11/30/23 at 1255 hours, an interview and concurrent record review was conducted with the Interim ED Nursing Director. The Interim ED Nursing Director verified Patient 20's EMTALA Transfer Acceptance or Denial form.

c. Review of the Transfer Center notes for Patient 20 dated 10/16/23, showed the following:

- At 1510 hours, according to an admitting staff, Patient 20 had an active health insurance and an authorization from the insurance was required for the patient's transfer.

- At 1513 hours, the Transfer Center Manager approved to bypass authorization from the insurance due to the emergent higher level of care for the patient.

On 11/29/23 at 1103 hours, an interview and concurrent record review was conducted with the Chief Quality and Patient Safety Officer. The Chief Quality and Patient Safety Officer verified the above findings. The Chief Quality and Patient Safety Officer stated an insurance information of a patient was not required for a transfer. The Chief Quality and Patient Safety Officer stated by asking insurance information could potentially delay the care of a patient or a patient would not further seek for a medical care.