HospitalInspections.org

Based on a tour of the Emergency Department (ED) and staff interview, conducted on June 5, 2013 at approximately 10:00 AM, it was determined that the facility failed to conspicuously post signage specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment of emergency medical conditions and women in labor or information indicating whether or not the hospital participates in the Medicaid program.

Findings include:

1. Observation of the main entrance to the ED revealed no signage posted.

2. Observation of the woman's and children's entrance revealed no signage posted.

3. Observation of the three triage areas in the ED revealed no signage posted.

4. Observation of the waiting area in the ED revealed only one sign posted.

5. Observation of the patient treatment bays in the ED revealed no signage posted.

6. Observation of the fast track treatment bays revealed no signage posted.

7. Observation of the pediatric treatment bays revealed no signage posted.

8. All of the above findings were confirmed by Staff #2.

Based on a review of the ED on call lists, it was determined that the facility failed to ensure that a physician on call list that identifies the name of an individual physician on call for all specialties, is maintained.

Findings include:

1. Review of the on call list for a Colon-Rectal specialist revealed that a physician group was listed as on call for 2013.

2. Review of the on call list for a Thoracic specialist revealed that a physician group was listed as on call for 2013.

3. Review of the on call list for a Urology specialist revealed that a physician group was listed as on call for 2013.

4. Review of the on call list for a Neurosurgeon specialist revealed that a physician group was listed as on call for 2013.

5. The above findings were confirmed by Staff #2.

Based on staff interview, medical record review and review of facility policy and procedure, it was determined that the facility failed to ensure that the EMTALA/Transfer form is completed and signed by the treating physician prior to patient transfer to another facility.

Finding include:

Reference: Facility policy number 950-55, titled, "The Emergency Medical Treatment and Active Labor Act (EMTALA)" states, "...IV. PROCEDURE:...7. Transfer of Individual to Another Facility: A. If an individual's medical condition cannot be stabilized without medical care beyond the capability of the facility and staff...that individual must be transferred to another facility. B. The individual, or parson acting on the individual's behalf, must be informed of Saint Peter's University Hospital's obligation to treat and admit all individuals requiring emergency care under EMTALA (Emergency Medical Treatment and Labor Act) as well as the risks and benefits of a transfer. The individual must sign consent to the transfer that outlines the risk and benefits...8. Physician Responsibilities When Transferring an Individual to Another Facility: Document an order for transfer in the medical record. Arrange for the acceptance of the transfer of care to a receiving attending and facility...Write transfer orders including the appropriate mode of transportation and equipment required. Explain the risks/benefits of the transfer and obtain consent from the individual or designee...A. A copy of the following information should be sent with the individual when transferring to another facility: Individual's consent to transfer; The reason for the transfer; The condition of the individual upon transfer; Transfer form..."

1. Documentation in Medical Record #12 states, "...4/28/2013 10:38 Disposition status is Transfer. Patient transferred to a psychiatric evaluation facility:____. Transfer/EMTALA consent not applicable..."

2. There was no evidence of the Transfer/EMTALA consent form in Medical Record #12. The absence of a written or electronic Transfer/EMTALA consent form was confirmed by Staff #2. Staff #2 stated, "I don't know how this happened. We have checklists in the computer to remind staff to complete the form."

3. There was no physician order for transfer, no mode of transportation, and no equipment required for transfer documented in Medical Record #12.

4. In Medical Record #12, the patient's condition upon transfer was not documented by the physician.