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Based on staff interviews and review of medical records, policies/procedures and Medical Staff Bylaws, the facility failed to comply with the Medicare provider agreement as defined in 489.20 and 489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

Findings:

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag A2405 Emergency Room Log
The facility failed to maintain a central log on each individual who came to the emergency department seeking assistance.

Tag A2407 Stabilizing Treatment
The facility failed to ensure that all individuals presenting the hospital's emergency department who were identified as having an emergency medical condition were provided further medical examination and treatment required to stabilize the medical condition in two (sample patients #25 and 29) of ten transferred patients' (sample patients #21, 22, 23, 24, 25, 26, 27, 28, 29, and 30) records reviewed.

Tag A2409 Appropriate Transfer
The facility failed to ensure that an appropriate transfer was effected in seven (sample patients #21, 22, 23, 25, 26, 28 and 30) of ten transferred patients' (sample patients #21, 22, 23, 24, 25, 26, 27, 28, 29, and 30) records reviewed.

Based on medical record review, facility document review, facility policy/procedure review, and staff interview the facility failed to maintain a central log on each individual who came to the emergency department seeking assistance.

Findings:

1. The facility failed to document in the central log when Sample patient #6 came to the obstetrical department with a complaint of pregnancy.

a. Policy/Procedure
The facility's policy, "EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT TREATMENT AND TRANSFER OF INDIVIDUALS WITH EMERGENCY MEDICAL CONDITIONS", stated:
"III. Procedures
F. Record-keeping.
The Hospital, whether transferring or receiving patients, must maintain the following for a minimum period of five (5) years:
3. a central log on each individual who comes to the Hospital, the emergency department, or any other location in the Hospital seeking examination. The log must include an indication whether the individual refused treatment or transfer, or was transferred, admitted and treated, stabilized and transferred, or discharged. Logs that are maintained in other departments that perform medical screening examinations, such as in labor and delivery, shall be deemed a part of the central log and are subject to the same requirements as the central log."

b. Facility Document Review (ED Log)
A review of the logs maintained by the obstetrical department and the emergency department that were identified as the facility's "Central Log" as required for this regulation was reviewed from 06/18/12 through 06/19/12. The pages for 05/04/11 did not contain Sample patient #6.

c. Medical Record Review
A review of Sample record #6 revealed that the patient in the record received care on 05/04/11. The documentation in the record consisted of a history and physical examination from an obstetrician which documented the interactions with the patient which concluded in the patient leaving without being seen.

d. Staff Interview
An interview was conducted on 06/19/12 at 11:32 a.m. with the Director of the Obstetrical Department. S/he confirmed that Sample patient #6 was not present on the "Central Log" and stated that patients that presented to the department but refused care are not placed in the log. S/he stated that the log was used for patient charges. S/he stated it was rare for the department to have patients leave against medical advice or leave without being seen was "very rare."

Based on medical record review, staff interview, and review of the facility's policies/procedures the facility failed to ensure that all individuals presenting the hospital's emergency department who were identified as having an emergency medical condition were provided further medical examination and treatment required to stabilize the medical condition in 2 (sample patients # 25 and 29) of ten transferred patients' (sample patients #21, 22, 23, 24, 25, 26, 27, 28, 29, and 30) records reviewed.

This failure had the potential to lead to patient death due to patient instability at the time of transfer to another facility when the facility had the capability to stabilize the patient further prior to transfer.

Findings:

1. The facility did not ensure that Sample Patients #25's and 29's conditions were stabilized prior to transfer to another facility.

a. Policy/Procedure
The facility's policy, "EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT TREATMENT AND TRANSFER OF INDIVIDUALS WITH EMERGENCY MEDICAL CONDITIONS", stated:
"I. Policies
A. It is the policy of SLV Regional Medical Center (the 'Hospital') in accordance with state and federal laws, including the Emergency Medical Treatment and Active Labor Act ('EMTALA'):
1. to provide a medical screening examination by a physician or Qualified Medical Person to any individual who comes to the designated emergency department ('ED'), or other department of the Hospital, seeking an examination or medical treatment to determine if the individual has an emergency medical condition.
2. if it is determined that the individual has an emergency medical condition, to provide the individual with such further medical examination and treatment as required to stabilize the emergency medical condition, within the capability of the Hospital, or to arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below;
II. Definitions
F. 'Qualified Medical Person' means an individual who is licensed or certified by the Hospital's Bylaws or Medical Staff Rules and Regulations in the following professional categories and who has demonstrated current competence in the performance of the medical screening examination:
Physicians
Birthplace Nurses for obstetrical patients.
G. 'To stabilize' or 'stabilize' or 'stabilized' means:
1. with respect to an emergency medical condition, that the patient is provided such medical treatment of the condition as is necessary to en sure, within reasonable medical probability, that no deterioration of the condition is likely to result from, or occur during, the transfer of the patient; or
3. the emergency medical condition has been resolved.
III. Procedures
A. Medical Screening Examination
1. The Hospital shall provide a medical screening examination for every individual who comes to the emergency department seeking medical treatment, and shall also provide such an examination for every person who comes to another area of the Hospital campus to seek treatment for an apparent emergency medical condition.
4. The medical screening examination is an ongoing process. The medical record must reflect continued monitoring, according to the patient's condition, which must continue until he is stabilized or appropriately admitted or transferred. The screening examination must be documented in the medical record.
C. Individuals Who Have An Emergency Medical Condition.
1. When it is determined that the individual has an emergency medical condition, the Hospital shall:
a. within the capability of the staff and facilities available at the Hospital, stabilize the individual to the point where the individual is either 'stable for discharge' or 'stable for transfer' as defined; or
b. provide for an appropriate transfer of the unstable individual to another medical facility in accordance with these procedures. Transfers of unstable individuals are allowed only pursuant to patient request, or when a physician or a Qualified Medical Person in consultation with a physician, certifies that the expected benefits to the patient from the transfer outweigh the risks of transfer."

The facility's policy, "TRANSFER OF PATIENT TO ANOTHER FACILITY", stated:
"Purpose:
Establish guidelines based on EMTALA standards to ensure that adequate care is given to each patient. If unable to continue with care, offer specialty care or higher level of care, patient is to be transferred to an appropriate facility.
Policy:
If the physician determines, through the hospital policy, that the patient should be transferred to another facility for further care, EMTALA standards must be followed:
The patient must:
Have no life threatening condition
Be medically stable
Agree to the transfer
Transfer papers will be completed:
Physician Authorization for Transfer form
Patient Transfer Acceptance or Refusal form
Physician Certification Medically for Transfer form
Transfer Summary form."

b. Medical Record Review
The medical record of Sample Patient #25 was reviewed from 06/20/12 through 06/21/12. The patient presented to the hospital's emergency department after having multiple falls, chest pain, neck and back pain, and weakness. The record contained documentation from the attending emergency department physician on a two-sided form titled, "Emergency Physician Record." The record had space provided for the physician to document the examination of the patient. The physician completed only two of the nine provided sections, leaving the sections for examination of the "neck/back, respiratory, cardiovascular, abdomen, skin, extremities, neurological/psychiatric" all blank. The patient was documented by the nursing staff to have had at least 4 episodes of "asystole" (an absence of a heart rhythm/electrical activity on the cardiac monitor) during his/her emergency visit. The physician also failed to document any progress of the patient throughout the stay in the space provided for such. The patient's medical record did not include documentation from the physician to indicate that the patient's recurrent episodes of syncope were stabilized. Additionally, the "Physician Assessment and Declaration for Transfer" form where the physician or qualified medical professional was to document the patient's condition and was left blank.

The medical record of Sample Patient #29 was reviewed from 06/20/12 through 06/21/12. The patient presented to the hospital's emergency department on 05/17/12 with a final diagnosis of new onset diabetes and gastroenteritis. The physician determined that the patient needed to be admitted. The patient's record stated "no beds." The patient was transferred to a CAH rather than being admitted to the facility. Prior to the transfer, the record did not reflect that the patient had been stabilized by the hospital. The patient's vital signs (blood pressure and pulse) were not within normal limits and were documented to be fluctuating. Additionally, the patient was demonstrated to have a blood glucose level of 309 which was not treated with insulin nor was the glucose level retested prior to transfer. The documentation from the treating physician did not address the patient's condition at the time of transfer including the patient's mental status, hypotension, tachycardia, or the treatment of the patient's hyperglycemia. Additionally, the "Physician Assessment and Declaration for Transfer" form where the physician or qualified medical professional was to document the patient's condition and was left blank.

c. Staff Interview
An interview was conducted on 06/21/12 at 2:29 p.m. with the facility's Risk Manager. S/he stated that it was expected for the physician to document on the "Physician Assessment and Declaration for Transfer" form. In a subsequent interview on 06/21/12 at 3:13 p.m., the Risk Manager stated that there needed to be staff education on the completion of forms and records.

An interview was conducted on 06/21/12 at 3:02 p.m. with the facility's Interim Chief Nursing Officer (CNO). S/he stated that it was expected for the physician to document on the "Physician Assessment and Declaration for Transfer" form. In a subsequent interview on 06/21/12 at 3:59 p.m., the Interim CNO stated that the ensuring that documentation was completed needed to be a "team effort."

An interview was conducted on 06/21/12 at 3:56 p.m. with the Director of the Emergency Department revealed that the nursing staff was expected to ensure that the nursing documentation was complete but that "as far as EMTALA paperwork that is the physicians' and the ward clerk's" responsibility. S/he stated that s/he had spoken to the ward clerks to ensure that they were checking to ensure that all the paperwork was included and complete. S/he stated that s/he felt that an audit for physician completion of their documentation may be necessary. S/he stated that s/he thought that the documentation was completed, but "we will have to audit them and get providers to improve their documentation."

An interview with the facility's Risk Manager conducted on 6/21/12 at 2:51 PM revealed that the attending physician for Sample patient #25 was a locum tenens physician and no longer practiced at the facility due to "being fired for inappropriate behavior." S/he confirmed that the physician failed to complete documentation in the patient's record.

Based on medical record review, staff interview, and review of the facility's policies/procedures the facility failed to ensure that an appropriate transfer was effected in 7 (sample patients #21, 22, 23, 25, 26, 28, and 30) of ten transferred patients' (sample patients #21, 22, 23, 24, 25, 26, 27, 28, 29, and 30) records reviewed.

Findings:

1. The facility inappropriately transferred three patients (Sample Patients #21, 22, and 28) to lower levels of care at Critical Access Hospitals that did not have the capability to treat the patient's emergency medical conditions that were identified at the facility.

a. Policy/Procedures
The facility's policy, "EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT TREATMENT AND TRANSFER OF INDIVIDUALS WITH EMERGENCY MEDICAL CONDITIONS", stated:
"I. Policies
A. It is the policy of SLV Regional Medical Center (the 'Hospital') in accordance with state and federal laws, including the Emergency Medical Treatment and Active Labor Act ('EMTALA'):
2. if it is determined that the individual has an emergency medical condition, to provide the individual with such further medical examination and treatment as required to stabilize the emergency medical condition, within the capability of the Hospital, or to arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below;
III. Procedures
C. Individuals Who Have An Emergency Medical Condition.
3. The transfer from this Hospital to a receiving facility of an individual with an unstable emergency medical condition shall be carried out in accordance with the following procedures:
b. A representative of the receiving facility must have confirmed that:
(1) the receiving facility has available space and qualified personnel to treat the individual; and
(2) the receiving facility has agreed to accept the transfer of the individual and to provide appropriate medical treatment."

The facility's policy, "TRANSFER OF PATIENT TO ANOTHER FACILITY", stated:
"Purpose:
Establish guidelines based on EMTALA standards to ensure that adequate care is given to each patient. If unable to continue with care, offer specialty care or higher level of care, patient is to be transferred to an appropriate facility.
Policy:
If the physician determines, through the hospital policy, that the patient should be transferred to another facility for further care, EMTALA standards must be followed:
Transfer papers will be completed:
Physician Authorization for Transfer form
Patient Transfer Acceptance or Refusal form
Physician Certification Medically for Transfer form
Transfer Summary form."

b. Medical Record Review
A review of Sample patient #21's record revealed that the patient presented to the facility's Emergency Department on 06/14/12 with dizziness and syncope. The patient was determined to have severe sepsis with hypotension. The patient required admission to the hospital to stabilize the patient's emergency medical condition. The patient required the services of a cardiologist consultation and possible intensive care admission which would be available at a higher level of care. The patient was rather transferred to a Critical Access Hospital without the services needed for this patient.

A review of Sample patient #22's record revealed that the patient presented to the facility's Emergency Department on 05/17/12 with chest pain. The patient had a history of similar chest pain that was attributed to a myocardial infarction (heart attack) and required intervention. The patient had stated that the pain felt the same as the previous episode of chest pain. The treating physician determined that the patient needed admission to stabilize the patient's emergency medical condition. The record indicated that there were no available beds in the facility. The patient would possibly require the services of a cardiologist consultation and possible intensive care unit admission which would have been available at a higher level of care. The patient was rather transferred to a Critical Access Hospital without the services needed for this patient.

A review of Sample patient #28's record revealed that the patient presented to the facility's Emergency Department on 05/04/12 with stroke-like symptoms. The patient was determined by the treating physician to have a stroke. The treating physician determined that the patient needed admission to stabilize the patient's emergency medical condition. The record indicated that there were no available beds in the facility. The patient would possibly require the services of a neurologist consultation and would have benefited from a facility with a dedicated stroke team which would have been available at a higher level of care. The patient was rather transferred to a Critical Access Hospital without the services needed for this patient.

2. The facility failed to ensure that there was documentation that the receiving facility had available space and qualified personnel for the treatment of the individual and agreed to accept the transfer of the individual to provide appropriate medical treatment in 7 (sample patients #21, 22, 23, 25, 26, 28, and 30) of ten transferred patients' (sample patients #21, 22, 23, 24, 25, 26, 27, 28, 29, and 30) records reviewed.

a. Policy/Procedure
The facility's policy, "EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT TREATMENT AND TRANSFER OF INDIVIDUALS WITH EMERGENCY MEDICAL CONDITIONS", stated:
"I. Policies
A. It is the policy of SLV Regional Medical Center (the 'Hospital') in accordance with state and federal laws, including the Emergency Medical Treatment and Active Labor Act ('EMTALA'):
2. if it is determined that the individual has an emergency medical condition, to provide the individual with such further medical examination and treatment as required to stabilize the emergency medical condition, within the capability of the Hospital, or to arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below;
III. Procedures
C. Individuals Who Have An Emergency Medical Condition.
3. The transfer from this Hospital to a receiving facility of an individual with an unstable emergency medical condition shall be carried out in accordance with the following procedures:
b. A representative of the receiving facility must have confirmed that:
(1) the receiving facility has available space and qualified personnel to treat the individual; and
(2) the receiving facility has agreed to accept the transfer of the individual and to provide appropriate medical treatment."

The facility's policy, "TRANSFER OF PATIENT TO ANOTHER FACILITY", stated:
"Purpose:
Establish guidelines based on EMTALA standards to ensure that adequate care is given to each patient. If unable to continue with care, offer specialty care or higher level of care, patient is to be transferred to an appropriate facility.
Policy:
If the physician determines, through the hospital policy, that the patient should be transferred to another facility for further care, EMTALA standards must be followed:
Transfer papers will be completed:
Physician Authorization for Transfer form
Patient Transfer Acceptance or Refusal form
Physician Certification Medically for Transfer form
Transfer Summary form."

b. Medical Record Review
A review of Sample patient #21's record revealed that the "Physician Assessment and Declaration for Transfer" form did not have documented the receiving facility's employee name and number that acknowledged that the receiving facility had available space and personnel for treatment and agreed to accept the transfer of the patient.

A review of Sample patient #22's record revealed that the "Physician Assessment and Declaration for Transfer" form did not have documented the receiving facility's employee name and number that acknowledged that the receiving facility had available space and personnel for treatment and agreed to accept the transfer of the patient.

A review of Sample patient #23's record revealed that there was not a "Physician Assessment and Declaration for Transfer" form in the record and therefore there was no documentation of the receiving facility's employee name and number that acknowledged that the receiving facility had available space and personnel for treatment and agreed to accept the transfer of the patient.

A review of Sample patient #25's record revealed that the "Physician Assessment and Declaration for Transfer" form did not have documented the receiving facility's employee name and number that acknowledged that the receiving facility had available space and personnel for treatment and agreed to accept the transfer of the patient.

A review of Sample patient #26's record revealed that the "Physician Assessment and Declaration for Transfer" form did not have documented the receiving facility's employee name and number that acknowledged that the receiving facility had available space and personnel for treatment and agreed to accept the transfer of the patient.

A review of Sample patient #28's record revealed that the "Physician Assessment and Declaration for Transfer" form did not have documented the receiving facility's employee name and number that acknowledged that the receiving facility had available space and personnel for treatment and agreed to accept the transfer of the patient.

A review of Sample patient #30's record revealed that the "Physician Assessment and Declaration for Transfer" form did not have documented the receiving facility's employee name and number that acknowledged that the receiving facility had available space and personnel for treatment and agreed to accept the transfer of the patient.

c. Staff Interview
An interview was conducted on 06/21/12 at 2:29 p.m. with the facility's Risk Manager. S/he stated that it was expected for the physician to document on the "Physician Assessment and Declaration for Transfer" form. S/he confirmed that Sample patient #23's record did not contain the "Physician Assessment and Declaration for Transfer" form. In a subsequent interview on 06/21/12 at 3:13 p.m., the Risk Manager stated that there needed to be staff education on the completion of forms and records.

An interview was conducted on 06/21/12 at 3:02 p.m. with the facility's Interim Chief Nursing Officer (CNO). S/he stated that it was expected for the physician to document on the "Physician Assessment and Declaration for Transfer" form. In a subsequent interview on 06/21/12 at 3:59 p.m., the Interim CNO stated that the ensuring that documentation was completed needed to be a "team effort."

An interview was conducted on 06/21/12 at 3:56 p.m. with the Director of the Emergency Department revealed that the nursing staff was expected to ensure that the nursing documentation was complete but that "as far as EMTALA paperwork that is the physicians' and the ward clerk's" responsibility. S/he stated that s/he had spoken to the ward clerks to ensure that they were checking to ensure that all the paperwork was included and complete. S/he stated that s/he felt that an audit for physician completion of their documentation may be necessary. S/he stated that s/he thought that the documentation was completed, but "we will have to audit them and get providers to improve their documentation."

3. The facility failed to ensure to obtain the informed written consent of the patient or their representative for the transfer of the individual in 3 (sample patients #22, 23, and 30) of ten transferred patients' (sample patients #21, 22, 23, 24, 25, 26, 27, 28, 29, and 30) records reviewed.

a. Policy/Procedure
The facility's policy, "EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT TREATMENT AND TRANSFER OF INDIVIDUALS WITH EMERGENCY MEDICAL CONDITIONS", stated:
"I. Policies
A. It is the policy of SLV Regional Medical Center (the 'Hospital') in accordance with state and federal laws, including the Emergency Medical Treatment and Active Labor Act ('EMTALA'):
2. if it is determined that the individual has an emergency medical condition, to provide the individual with such further medical examination and treatment as required to stabilize the emergency medical condition, within the capability of the Hospital, or to arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below;
III. Procedures
C. Individuals Who Have An Emergency Medical Condition.
3. The transfer from this Hospital to a receiving facility of an individual with an unstable emergency medical condition shall be carried out in accordance with the following procedures:
f. Unless the individual or a legally responsible person requested the transfer, the Hospital shall if at all possible notify the person or, where applicable, the individual's legally responsible person, both orally and in writing, of the decision and reasoning for the transfer. The individual or the legally responsible person should then be asked to sign the 'Transfer Consent' portion of the EMTALA Transfer Form."

b. Medical Record Review
A review of sample patient #22's record revealed that the "Patient Transfer: Consent, Request or Refusal" form was signed by the patient or the patient's representative, but there was no indication if the individual consented for or refused the transfer.

A review of sample patient #23's record revealed that the "Patient Transfer: Consent, Request or Refusal" form was signed by the patient or the patient's representative, but there was no indication if the individual consented for or refused the transfer.

A review of sample patient #30's record revealed that the "Patient Transfer: Consent, Request or Refusal" form was not signed by the patient or the patient's representative. There was no documentation that the patient or a representative was not available. Additionally, the patient had signed the consent for the treatment at the facility earlier in the patient's stay.

4. The facility failed to send to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer (including available history, records related to the individual's emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests) in 3 (sample patients #21, 22, and 28) of ten transferred patients' (sample patients #21, 22, 23, 24, 25, 26, 27, 28, 29, and 30) records reviewed.

a. Policy/Procedure
The facility's policy, "EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT TREATMENT AND TRANSFER OF INDIVIDUALS WITH EMERGENCY MEDICAL CONDITIONS", stated:
"I. Policies
A. It is the policy of SLV Regional Medical Center (the 'Hospital') in accordance with state and federal laws, including the Emergency Medical Treatment and Active Labor Act ('EMTALA'):
2. if it is determined that the individual has an emergency medical condition, to provide the individual with such further medical examination and treatment as required to stabilize the emergency medical condition, within the capability of the Hospital, or to arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below;
III. Procedures
C. Individuals Who Have An Emergency Medical Condition.
3. The transfer from this Hospital to a receiving facility of an individual with an unstable emergency medical condition shall be carried out in accordance with the following procedures:
c. The Hospital shall send the receiving facility copies of all pertinent medical records available at the time of the transfer, including: (1) history; (2) records related to the individual's emergency medical condition; (3) observations of signs and symptoms; (4) preliminary diagnoses; (5) results of diagnostic studies or telephone reports of the studies; (6) treatment provided; (7) results of any tests; and (a copy of the completed applicable sections of the EMTALA Transfer Form. Records received after the transfer should be forwarded to the receiving facility."

The facility's policy, "TRANSFER OF PATIENT TO ANOTHER FACILITY", stated:
"Purpose:
Establish guidelines based on EMTALA standards to ensure that adequate care is given to each patient. If unable to continue with care, offer specialty care or higher level of care, patient is to be transferred to an appropriate facility.
Policy:
If the physician determines, through the hospital policy, that the patient should be transferred to another facility for further care, EMTALA standards must be followed:
Copy of medical records, lab and x-rays will accompany the patient.
Documentation shall include, but is not limited to:
Report given to transport team
Condition of the patient prior to transfer
Vital signs prior to transfer."

b. Medical Record Review
A review of the records sent to the receiving facility for Sample patent #21 revealed that the documentation sent with the patient did not include complete nursing notes. The nursing notes that remained at the sending facility included assessment data and notes that were not included in the transfer record.

A review of the records sent to the receiving facility for Sample patent #22 revealed that the documentation sent with the patient did not include complete nursing notes. The nursing notes that remained at the sending facility included assessment data and notes that were not included in the transfer record. Additionally, printouts of the patient's vital signs were not sent with the patient and were not documented elsewhere in the patient's record.

A review of the records sent to the receiving facility for Sample patent #28 revealed that the documentation sent with the patient did not include complete nursing notes. The nursing notes that remained at the sending facility included assessment data and notes that were not included in the transfer record. Additionally, printouts of the patient's vital signs were not sent with the patient and were not documented elsewhere in the patient's record.

c. Staff Interview
An interview with the nurse that cared for Sample patient #22 conducted on 06/20/12 at 4:20 p.m. revealed that s/he had went off shift prior to the patient's transfer. S/he stated that the ward clerk made copies of paperwork to go with patient including the patient record. When asked why the notes that the receiving facility received were incomplete, s/he stated that the facility had a "full ER that day" and that normally s/he would have filled out his/her notes "after my shift." S/he stated that normally s/he would not send updated records. S/he stated that s/he thought that s/he completed his/her documentation the "next day when I came to work."

An interview with the facility's Director of the Emergency Department conducted on 06/21/12 at 3:56 p.m. revealed that nursing staff was expected to ensure that the documentation was complete (including nursing notes, vital signs, etc.). S/he stated that s/he had spoken with the ward clerks to ensure that they are checking to ensure that all the paperwork was included and complete.

5. The facility transferred three patients (sample patients #21, 22, and 28) to critical access hospitals when the facility had beds available in the facility.

a. Policy/Procedure
The facility's policy, "EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT TREATMENT AND TRANSFER OF INDIVIDUALS WITH EMERGENCY MEDICAL CONDITIONS", stated:
"I. Policies
A. It is the policy of SLV Regional Medical Center (the 'Hospital') in accordance with state and federal laws, including the Emergency Medical Treatment and Active Labor Act ('EMTALA'):
2. if it is determined that the individual has an emergency medical condition, to provide the individual with such further medical examination and treatment as required to stabilize the emergency medical condition, within the capability of the Hospital, or to arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below;
II. Definitions
G. 'To stabilize' or 'stabilize' or 'stabilized' means:
1. with respect to an emergency medical condition, that the patient is provided such medical treatment of the condition as is necessary to en sure, within reasonable medical probability, that no deterioration of the condition is likely to result from, or occur during, the transfer of the patient; or
3. the emergency medical condition has been resolved.
III. Procedures
C. Individuals Who Have An Emergency Medical Condition.
1. When it is determined that the individual has an emergency medical condition, the Hospital shall:
a. within the capability of the staff and facilities available at the Hospital, stabilize the individual to the point where the individual is either 'stable for discharge' or 'stable for transfer' as defined; or
b. provide for an appropriate transfer of the unstable individual to another medical facility in accordance with these procedures. Transfers of unstable individuals are allowed only pursuant to patient request, or when a physician or a Qualified Medical Person in consultation with a physician, certifies that the expected benefits to the patient from the transfer outweigh the risks of transfer."

The facility's policy, "Patient Diversion", last reviewed 07/08, stated:
"Purpose:
To assure that all patients receive safe care, the same standards of care, and the appropriate level of care while avoiding, whenever possible, the diversion of patients.
Policy Statement:
Inpatient Patient Diversion
Patients will not be admitted to SLVRMC if their minimum/essential nursing care requirements can not be met, there is another facility willing to accept the patient that can meet those needs, and the patient is stable for transfer. Patients will also not be admitted if there are no appropriate bed assignments. Diversionary status/Condition Yellow will be authorized by the Chief Nursing Officer (CNO) or another Senior Management member in consultation with the President of the Medical Staff or other Medical Staff Officer."

b. Medical Record Review
A review of Sample record #21 revealed that the patient presented to the hospital's emergency department on 06/14/12 with a final diagnosis of syncope and septicemia. The physician determined that the patient needed to be admitted. The patient's record stated that "SLVRMC currently has no available beds." The patient was transferred to a critical access hospital (CAH) rather than being admitted to the facility. A review of the patient's record from the receiving hospital revealed that the patient had to be transferred to an acute care hospital after his/her hemoglobin and hematocrit continued to decrease requiring a blood transfusion and further work-up.

A review of Sample record #22 revealed that the patient presented to the hospital's emergency on 05/17/12 department with a final diagnosis of chest pain. The physician determined that the patient needed to be admitted. The patient's record stated that "no bed here." The patient was transferred to a CAH rather than being admitted to the facility. A review of the patient's record from the receiving facility revealed that the patient had to be transferred to an acute care hospital after s/he experienced chest pain during the transfer to the CAH and required cardiac consultation.

A review of Sample record #28 revealed that the patient presented to the hospital's emergency department on 05/04/12 with a final diagnosis of an ischemic Cerebral Vascular Accident (stroke). The physician determined that the patient needed to be admitted. The patient's record stated that "transfer to [CAH] no bed available upstairs for admission." The patient was transferred to a CAH rather than being admitted to the facility.

c. Facility Record Review (logs/census reports, staffing schedules)
A review of the facility's Emergency Department logs from past 6 months revealed that three (sample records #21, 22, and 28) patients had been transferred to critical access hospitals from the facility in past three months (on 05/04/12, 05/17/12, and 06/14/12).

A review of the facility's daily census counts and staffing sheets revealed that on 05/04/12 the facility had 15 medical/surgical and 6 ICU patients and 11 medical/surgical vacant beds and 0 ICU vacant beds. The facility had 3 day shift and 3 nightshift medical/surgical nurses.
A review of the emergency department log for 05/04/12 revealed that out of the 5 patients that presented on 05/04/12 that required admission to medical/surgical (including Sample patient #28), there were 4 patients admitted after Sample patient #28 was transferred to a CAH.

A review of the facility's daily census counts and staffing sheets revealed that on 05/17/12 the facility had 14 medical/surgical and 5 ICU patients and 12 medical/surgical vacant beds and 1 ICU vacant bed. The facility had 3 day shift and 3 nightshift medical/surgical nurses.
A review of the emergency department log for 05/17/12 revealed that out of the 4 patients that presented on 05/17/12 that required admission to medical/surgical (including Sample patient #22), there were 2 patients admitted prior to Sample patient #22 being transferred to a CAH.

A review of the facility's daily census counts and staffing sheets revealed that on 06/14/12 the facility had 16 medical/surgical and 4 ICU patients and 10 medical/surgical vacant beds and 2 ICU vacant beds. The facility had 3 day shift (and 1 orientee) and 4 nightshift (and 1 orientee) medical/surgical nurses.
A review of the emergency department log for 06/14/12 revealed that out of the 6 patients that presented on 06/14/12 that required admission to medical/surgical (including Sample patient #21), there were 4 patients admitted prior to Sample patient #21 being transferred to a CAH and 1 patient admitted after Sample patient #21 was transferred to a CAH.

d. Staff Interview
An interview conducted on 06/20/12 at 2:03 p.m. with the facility's Risk Manager revealed that the facility's emergency department had never gone on divert. S/he stated that the medical/surgical floor was short staffed on that night (6/14/12 when sample patient #21 was transferred to a CAH) and was the same case when patient (sample #22) went to another CAH (on 5/17/12). S/he stated that the hospital did not keep track of how often the floor had been on divert. A subsequent interview with the Risk Manager on 06/21/12 at 12:52 p.m. s/he stated that sample patient #21 had to be transferred to an acute care hospital after being transferred to the CAH due to his/her hematocrit level was not stable. On 06/21/12 at 3:04 p.m. the Risk Manager stated that on 5/17/12 the Medical/Surgical Nursing Department Director was the Nursing Director on-call and approved that the facility could transfer admits. S/he stated that on 06/14/12 the Administrator on-call approved that the facility could transfer admits. S/he stated that on 05/04/12 the facility's Administrator on-call approved that the facility could transfer admits.

An interview conducted on 06/20/12 at 3:30 p.m. with the facility's Interim Chief Nursing Officer (CNO) revealed that the facility had difficulty ensuring that it had enough nurses to care for the patients that required admission. S/he stated that on 05/17/12 the Nursing Director on-call or the Administrator on-call was not consulted. S/he stated that education had been provided to the staff that the charge nurses were required to contact the Nursing Director on-call when the staff felt that they could not admit a patient due to staffing. A subsequent interview on 06/21/12 at 2:20 p.m. with the Interim CNO revealed that the hospital had 6 total beds available in the ICU and 26 total available beds in the Medical/Surgical Nursing Care Unit.