HospitalInspections.org

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Based on observation, interview, record review and review of hospital policies and procedures, the hospital failed to develop and implement policies and procedures for evaluation, treatment and appropriate transfer or discharge of patients presenting for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to ensure patients receive a comprehensive medical screening examination by a qualified medical professional and stabilizing treatment prior to transfer or discharge risks poor health care outcomes, injury, and death.

Findings included:

1. The hospital failed to ensure that patients who decided to leave the hospital's ED against medical advice (AMA) would have documented that on the hospital's "Leaving Hospital Against Medical Advice" form for 3 of 5 patients who left against medical advice.

2. The hospital failed to ensure that a patient's emergency medical condition was stabilized prior to discharging from the Emergency Department in 1 of 25 medical records reviewed.

Cross Reference: C 2407

3. The hospital failed to ensure that patients being transferred to other facilities had documentation on the hospital's "Interfacility Transfer Form" for 1 of 4 patients transferred to another facility.

Cross Reference: C 2409
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ITEM #1 Leaving Against Medical Advice
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Based on interview, document review and review of hospital policies and procedures, the hospital failed to obtain, or attempt to obtain, a written refusal of care for 2 of 5 patients leaving against medical advice (AMA) (Patient #21, Patient #22).

Failure to obtain a written refusal risks patients' lack of understanding of the risks and benefits of remaining at the facility until an appropriate transfer for care could be facilitated resulting in possible patient injury or death.

Findings included:

1. Review of the hospital's policy titled, "Leaving Against Medical Advice/Leaving Without Being Seen/Elopement," number 10904014, revised 01/22, showed that if , after being informed by a provider of the medical consequences of leaving the hospital against medical advice, an adult patient with capacity to make health decisions wished to be discharged or to leave AMA, the provider would ask the patient to sign the "Leaving Against Medical Advice" form. The provider shall document in the patient's medical record:

a. That the patient was discharged or left AMA:

b. The potential medical consequences of the patient's decision; and

c. That the provider discussed the medical consequences with the patient

If the patient refused to sign the AMA form, the provider should have a nurse or other member of the patient's healthcare team witness their conversation explaining the medical consequences of the patient's decision to leave AMA. The provider shall document in the medical record:

a. That the patient was being discharged AMA;

b. The specific potential medical consequences to the patient of their discharge AMA;

c. That the medical consequences were explained to the patient;

d. That the patient refused to sign the form;

e. That the patient had capacity to make informed decisions regarding their healthcare; and

f. The name and title of the staff member who witnessed the discussion

2. Review of the medical records showed that a patient arrived in the ED on 04/14/23 with a complaint of head injury from a fall and fatigue. A medical screening examination was performed. Lab results showed that the patient had Leukocytosis (an elevation of white blood cells in the blood). The patient told hospital staff that they wanted to go home if they couldn't get methadone. The patient "fired" their initial nurse as well as the ED technician and the second nurse and demanded to go home. The patient's results had not all been received, but the patient left the ED. There was no AMA form located in the medical record (Patient #21).

3. On 06/02/23 at 1:40 PM, during an interview with the investigator, the ED Director (Staff #4) verified that the medical records for Patient #18 and Patient #21 did not include an AMA form.

ITEM #2 Stabilization prior to discharge

Based on interview, document review and review of hospital policies and procedures, the hospital failed to stabilize the emergency medical condition prior to the patient being discharged from the ED for 1 of 18 records reviewed (Patient #1).

Failure to stabilize the medical condition prior to discharge risks poor patient outcomes, injury, or death.

Findings included:

1. Review of the hospital's policy titled, "Emergency Nursing Standards and Process of Care," number 13510429, revised 05/23, showed that individual patient disposition was determined based on situation, stability, and was at the discretion of the patient's physician.

2. Review of the hospital's policy titled, "Discharge Planning (Transition Planning)," number 12210202, approved 03/22, showed that the medical staff, the care team, the patient, and the family collaborate to determine a reasonable discharge plan. The medical staff roles/responsibilities included participation in all phases of the discharge planning process and writing discharge orders as early as possible the day of discharge. Nursing staff roles/responsibilities included at the point of discharge, to verify and document the patient's actual (vs. expected) discharge disposition and destination.

3. Medical record review of Patient #1 showed that the patient had been in the ED 3 times in 3 days. The patient was brought in by police on 11/23/22, under arrest for domestic violence. During the altercation, the patient had held a knife to their neck, and created a small laceration. The ED provider completed a medical screening examination. The laceration did not require sutures. The patient was placed on an involuntary 72 hour hold. The patient was discharged to jail with the police. The following day the police returned the patient to the ED because the involuntary hold remained in effect. The patient had received a court date, and was therefore released from the jail. The patient was seen by the ED provider, and a medical screening examination was done. The patient was agitated, making fists, and pacing in their treatment room. The patient walked out of the room with arms held out in a stop position, hitting a nurse in the chest and a technician in the arm. The patient was told to return to their room and did so. The nurse contacted the police to file assault charges. The police returned to the ED, arrested the patient and took them to jail. On 11/26/22 the police returned the patient to the ED because a court date had been set, and the 72 hour involuntary hold remained in effect. The patient again was pacing, clenching their fists, and doing push ups in their treatment room. The medical record did not show that a discharge order was written by a provider. Nursing notes showed that discharge instructions were provided to the patient and the patient was escorted out of the ED (Patient #1).

4. On 06/02/23 at 2:00 PM, during an interview with the investigator, the Emergency Department Director (Staff #4) stated that staff did not follow hospital policies and procedures when discharging Patient #1.
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Based on interview, document review, and review of hospital policies and procedures, the hospital failed to ensure that documentation of patient transfers were in compliance with CMS EMTALA regulations for 1 of 4 patients transferred to other facilities (Patient # 3).

Failure to provide complete documentation of patient consent, physician certification, receiving hospital acceptance, and physician to physician and nurse to nurse communication risks inappropriate transfer and poor patient outcomes.

Findings included:

1. Review of the hospital policy titled, "Patient Transfer and Transport to Another Facility, number 10904001, revised 03/17, showed that the provider complete and document:

a. An examination of the patient to determine suitability for transfer/transport.

b. If the patient is stable, or if unstable, if the benefits of transfer outweigh the risks of transfer

c. Discuss with the patient and /or family of the rationale for the transfer and obtain consent for the transfer.

Nursing responsibilities included:

a. Contacting the transport agency as requested by the physician and specify the level of care required for transport

b. Compile copies of the medical record

c. Contact the receiving facility to provide a report to the receiving RN to verify acceptance of the transfer, completing a nurse to nurse handoff

d. Complete and sign the nursing portion of the Transfer Consent Form

2. Medical record review showed that 1 of 4 patients transferred to another facility did not include a Patient Transfer Consent Form, as required by hospital policy (Patient #3).

3. On 06/02/23 at 1:39 PM, during an interview with the investigator, the ED Director, (Staff #4) stated that there was no Patient Transfer Consent Form in the medical record of Patient #3.
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