HospitalInspections.org

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Based on interview, medical record review, and review of hospital policies and procedures, the hospital failed to maintain medical records of individuals transferred to or from the emergency department, failed to maintain a central log on each individual who comes to the ED seeking assistance and whether the individual refused treatment, was refused treatment, was treated, transferred, admitted or discharged, stabilized and transferred, or left against medical advice (AMA), failed to implement policies and procedures to ensure that all patients seeking emergency treatment receive a medical screening exam, failed to ensure that all qualified medical professionals demonstrated competency before performing medical screening exams, and failed to follow policies and procedures for transferring patients with emergency medical conditions to other acute care emergency departments.

Failure to maintain medical records of all individuals transferred to or from the emergency department, failure to maintain an accurate central log, failure to ensure that all patients seeking emergency medical treatment receive a medical screening exam from a qualified medical professional (QMP), failure to ensure that all QMPs demonstrate competency to perform medical screening exams, and failure to transfer patients with emergency medical conditions to other acute care emergency departments according to hospital policies and procedures risks poor patient outcomes, injury, and death.

Findings included:

The hospital failed to maintain medical records of individuals transferred to or from the emergency department for 6 of 6 patient records reviewed (Patients #5, #9, #10, #11, #20, and #23).

Cross reference: Tag A2403

The hospital failed to maintain a central log on each individual who comes to the hospital seeking emergency medical treatment and whether the individual refused treatment, was refused treatment, was treated, transferred, admitted or discharged, stabilized and transferred, or left against medical advice (AMA) for 150 of 191 records reviewed.

Cross reference: Tag A2405

The hospital failed to implement its policies and procedures to ensure that all patients on hospital grounds seeking emergency medical care receive a medical screening exam in accordance with the Emergency Medical Treatment and Labor Act (EMTALA) for 10 of 24 patient records reviewed (Patients #5, #9, #10, #14, #17, #19, #20, #21, #22, and #23).

The hospital failed to ensure that all qualified medical persons (QMPs) demonstrated competency before performing medical screening exams.

Cross reference: Tag A2406

The hospital failed to follow policies and procedures for transferring patients with emergency medical conditions to other acute care hospitals for 5 of 24 patient records reviewed (Patients #5, #9, #10, #19, and #22).

Cross reference: Tag A2409
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Based on interview, patient record review, and review of hospital documents, the hospital failed to maintain medical records of individuals transferred to or from the facility for 6 of 6 records reviewed (Patients #5, #9, #10, #11, #20, and #23).

Failure to maintain medical records of individuals transferred to or from the hospital risks poor healthcare outcomes from impaired care continuity during subsequent healthcare encounters.

Findings included:

1. Review of the hospital policy titled, "EMTALA Guidelines," last reviewed 03/21, showed the following:

a. All individuals who come to the hospital intake department seeking assistance with a medical condition, or come onto the hospital property for assistance with an emergency medical condition, will receive a medical screening exam and appropriate stabilizing treatment from a Qualified Medical Person (QMP) prior to any decisions regarding admission, discharge, transfer, or referral.

b. If an emergency medical condition is identified during the medical screening exam, hospital staff will provide stabilizing treatment and proceed with the standard admission process provided that the hospital has the capability and capacity to treat.

c. If the hospital is unable to provide stabilizing medical treatment or does not have the capability or capacity to treat the individual, the on-call provider will evaluate the patient for transfer to another acute care facility.

d. If a physician determines that an immediate transfer is medically appropriate, a certification that the medical benefits outweigh the increased risks of transfer to the individual will be documented and signed by the physician within 24 hours. If the order to transfer is given by phone the QMP will sign the certification, and the physician shall countersign the document within 24 hours.

e. When an individual being treated for an emergency medical condition requests a transfer to another hospital, the request must be in writing on the Patient Refusal of Medical/Psychiatric Treatment or Transfer form.

f. Prior to transfer, hospital staff will obtain the verbal agreement of the receiving hospital and accepting physician. The facility shall document its communication with the receiving hospital, including the date and time of the transfer request and the name of the accepting physician on the Transfer Form.

g. The transferring hospital should document the following information on the Memorandum of Transfer form:

i. The receiving facility's agreement to accept the patient

ii. The individual's request for transfer, or

iii. The physician's certification that the transfer is medically necessary and appropriate

iv. That all applicable medical records were transferred with the patient

v. The transfer was made with appropriately qualified and trained personnel and medically necessary life-support equipment.

h. Prior to transferring an individual with an emergency medical condition, staff will review the risks and benefits of transfer with the patient. The individual should sign the Consent/Refusal of Medical/Psychiatric Treatment or Transfer form.

i. In all cases, when a patient or legal guardian refuses to sign the Consent/Refusal of Medical/Psychiatric Treatment or Transfer form, this will be noted on the consent form and witnessed by a second staff member.

j. Upon determining that an individual transferred to the facility did not meet the hospital's admission criteria, the admissions representative may refuse to accept the transfer. Refusal to accept transfer will be documented, including the specific reasons for the refusal.

2. Review of the hospital's EMTALA logs dated 09/01/22 to 03/15/23, showed the following:

a. The hospital transferred 5 of 24 patients to the ED (Patients #5, #9, #10, #20, and #23).

b. The hospital refused to accept 1 transfer from another facility (Patient #11) because the patient did not meet the admission criteria.

3. Review of medical records showed that the hospital failed to complete or maintain medical records, including medical screening exams, documentation of consent or refusal of transfer, provider certification of transfer documents, and documentation of refusal to accept transfer for 6 of 6 patient records reviewed (Patients #5, #9, #10, #20, and #23).

4. On 03/16/23 at 2:30 PM, the investigator interviewed the hospital's interim Director of Admissions/Intake (Staff #1) regarding the information found in Patient #1's medical records. Staff #1 confirmed the investigator's findings of the missing documentation as required by hospital policy.
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Based on interview and review of hospital documents, the hospital failed to maintain a central log on each individual who comes to the hospital seeking emergency medical treatment and whether the individual refused treatment, was refused treatment, was treated, transferred, admitted or discharged, stabilized and transferred, or left against medical advice (AMA) for 150 of 191 records reviewed.

Failure to maintain an accurate central log decreases the hospital's ability to track the care provided to each individual seeking care for an emergency medical condition.

Findings included:

1. Document review of the hospital's policy titled, "EMTALA compliance," policy #L.EC.100, last reviewed 01/21, showed that the Admissions Department will maintain a log on each individual presenting to the hospital seeking assistance and whether the individual refused treatment, was refused treatment, was treated, transferred, admitted or discharged, stabilized, or left against medical advice.

2. Review of the hospital's "EMTALA Log" for visits dated between 09/01/22 and 03/15/23 showed that staff failed to document whether the individual refused treatment, was refused treatment, was treated, transferred, admitted or discharged, stabilized and transferred, or left against medical advice (AMA) for 150 of 191 records reviewed.

3. On 03/16/23 at 3:00 PM, the investigator interviewed the interim Director of Admissions/Intake (Staff #1). Staff #1 confirmed the investigator's finding that staff did not complete the central "EMTALA Log" according to hospital policy.
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Based on interview and document review, the hospital failed to implement its policies and procedures to ensure that all patients on hospital grounds seeking emergency medical care receive a medical screening exam in accordance with the Emergency Medical Treatment and Labor Act (EMTALA) for 10 of 24 patient records reviewed (Patients #5, #9, #10, #14, #17, #19, #20, #21, #22, and #23) (item #1), and the hospital failed to ensure that all qualified medical persons (QMPs) demonstrated competency before performing medical screening exams (item #2).

Failure to ensure that all patients seeking emergency medical treatment receive a medical screening exam from a qualified medical person, and failure to ensure that all qualified medical persons demonstrate competency to perform medical screening exams risks poor health outcomes, injury, and death.


Item #1 - Medical Screening Exams

Findings included:

1. Document review of the hospital policy titled, "EMTALA," policy #L.E.101, last reviewed 01/21, showed that any person who presents to the hospital will be evaluated to determine whether the person has an emergency medical condition. A medical record is established for each individual seeking emergency treatment at the hospital and will include a medical screening examination.

2. The investigator reviewed the hospital's "EMTALA Log" and requested the medical records from 24 patient visits between 09/01/22 to 03/15/23. The review showed the following:

a. The hospital was unable to provide documentation of a medical screening exam on the dates selected for 3 of 24 patients (Patients #5, #9, and #10).

b. The hospital was unable to provide any medical record documentation of visits for 6 of 24 patient records requested (Patients #17, #19, #20, #21, #22, and #23).

c. The medical screening exam for Patient #14 was incomplete and did not include a date or time of exam, assessment findings, patient disposition, or the signature of the qualified medical person (QMP) performing the exam.

3. On 03/16/23 at 3:00 PM, the investigator interviewed the interim Director of Admissions/Intake (Staff #1). Staff #1 confirmed the investigator's finding that staff did not complete the medical screening exam documentation according to hospital policy.


Item #2 - Demonstrated Competency of Medical Screening Exams

Findings included:

1. Review of the hospital document titled, "Cascade Behavioral Health Hospital Medical Staff Bylaws," effective 06/07/21, showed that physicians, nurse practitioners, physician assistants and registered nurses (RNs) are recognized as qualified medical professionals (QMP).

Review of the hospital policy titled, "EMTALA," policy #L.E.101, last reviewed 01/21, showed that in the absence of a physician, a designated qualified medical professional (QMP) who has demonstrated competency may conduct medical screening exams.

2. On 03/16/23 at 1:30 PM, the investigator and the Director of Human Resources (Staff #2) reviewed the personnel and training records of 3 RNs working in the admissions/intake department. The review showed that 3 of 3 RNs lacked documentation of competency to perform medical screening exams (Staff #3, #4, and #5).

3. On 03/16/23 at 4:00 PM, Staff #2 confirmed that the hospital did not have a formal process to ensure competency of the RNs performing medical screening exams.
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Based on interview, document review and medical record review, the hospital failed to follow policies and procedures for transferring patients with emergency medical conditions to other acute care hospitals for 5 of 24 patient records reviewed (Patients #5, #9, #10, #19, and #22).

Failure to follow policies and procedures designed to provide clear communication between the patient, provider and receiving facility risks delay in patient care and poor patient outcomes, including death.

Findings included:

1. Document review of the hospital policy titled, "EMTALA Guidelines)," policy #PC.A.2, last reviewed 03/21, showed the following:

a. If a physician determines that an immediate transfer of an individual is medically appropriate, a certification that the medical benefits outweigh the increased risks of transfer to the individual will be documented and signed by the physician within 24 hours. If physician instructions are obtained by phone, the certification shall be documented by a non-physician qualified medical person (QMP) receiving the instructions and countersigned by the physician within 24 hours.

b. Prior to transfer, hospital staff will obtain verbal agreement of the receiving hospital and physician accepting the transfer. The facility shall document its communication with the receiving hospital, including the date and time of the transfer request and the name of the person accepting the transfer on the Transfer form.

c. The transferring hospital should document the following on the Memorandum of Transfer form:

i. The receiving facility's agreement to accept the individual

ii. The individual's request for transfer; or

iii. The physician certification that the transfer is medically necessary and appropriate

iv. That all applicable medical records were transferred with the patient

v. The transfer was made with appropriate and qualified trained personnel and medically necessary life-support systems

d. Prior to transferring an individual with an emergency medical condition, staff will review with the individual or the individual's legal guardian the risks and benefits of the transfer to the second facility. Hospital staff should discuss with the individual or the individual's representative, the right to refuse the transfer.


Review of the hospital policy titled, "Patient Transfer to Another Facility," policy #PC.TAF.101, last revised 09/21, showed that when transferring a patient with a medical emergency not admitted to the facility, the risks and benefits of the transfer shall be explained to the patient (and/or family or guardian) and documented on the Consent/Refusal form.

2. The investigator reviewed the hospital's "EMTALA Log" and requested the medical records from 24 patient visits between 09/01/22 to 03/15/23. Review of the EMTALA Log showed that 5 of the 24 patients selected were transferred to the emergency department (ED). Medical record review showed that the hospital was unable to provide any documentation of an ED visit on the dates selected for 5 of 5 patients (Patients #5, #9, #10, #19, and #22).

3. On 03/16/23 at 3:00 PM, the investigator interviewed the interim Director of Admissions/Intake (Staff #1). Staff #1 confirmed the investigator's finding that staff did not complete the documentation for patient transfer according to hospital policy.
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