HospitalInspections.org

Based on observation, interview, review of documentation in the medical records for 7 of 17 patients who presented to the hospital for emergency services (Patients 1, 2, 3, 4, 14, 15 and 16), review of medical staff rules and regulations, review of hospital policies and procedures, review of staff training records, and review of event report documentation, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure compliance in the following areas:
* Required posting of EMTALA signs;
* Provision of MSEs;
* Stabilizing treatment of patients; and
* Appropriate transfers of patients.

Findings include:

1. Regarding the posting of signs refer to the findings identified under Tag A2402, CFR 489.20(q).

2. Regarding provisions of MSEs refer to the findings identified under Tag A2406, CFR 489.24(a) & (c).

3. Regarding stabilizing treatment refer to the findings identified under Tag A2407, CFR 489.24(d)(1-3).

4. Regarding appropriate transfers refer to the findings identified under Tag A2409, CFR 489.24(e)(1)-(2).


40575

Based on observation, interview and review of policies and procedures, it was determined the hospital failed to enforce EMTALA policies and procedures that ensured the posting of signage that specified patients' EMTALA rights in all areas likely to be noticed and where patients waited for examination and treatment.

Findings include:

1. The hospital policy and procedure titled "Emergency Medical Treatment And Labor Act (EMTALA) Compliance For Legacy Health Emergency, Labor And Delivery, Psychiatric Emergency Services And Provider Based Urgent Care Departments; On-Call Licensed Independent Practitioners & Reporting Requirements For Non-Compliance," dated last revised "01/17" was reviewed. It reflected:
* "Purpose of Signage: EMTALA signage provides all patients with the opportunity to receive notice of their right to a MSE and stabilization for an EMC."
* "Signage shall be posted in Legacy's DEDs and any other place likely to be noticed by all individuals entering these departments and those individuals waiting for examination and treatment in areas of the hospital other than the traditional emergency department ... appropriate signage notifying individuals of their right to an MSE and stabilization or treatment for an EMC and required services for women in labor as specified under EMTALA."

2. During tour of the FBC on 10/10/2019 at 1100 with FBC NM and ACC, it was observed that the department had one locked primary ambulatory entrance. Staff present during the tour confirmed that individuals who were in labor presented to the FBC at that entrance for an MSE. EMTALA signage was observed at the entrance to the FBC and the FBC Nurse's Station. There were no EMTALA signs observed in the designated triage rooms (rooms 70 and 71) where patients were examined and waited for further stabilizing treatment. These findings were confirmed with the FBC NM at the time of the observations on 10/10/2019.



40575

Based on interview, review of medical record and event report documentation for a patient who was 39 weeks pregnant and having contractions and "severe range" blood pressure (Patient 4), review of medical staff rules and regulations, review of policies and procedures, and review of staff training records, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure the provision of complete, accurate, and appropriate MSEs by LIPs and qualified RNs for all individuals who presented to the hospital for emergency services.
* MSEs for pregnant individuals who presented to the hospital for emergency services were not always conducted by LIPs, but rather by RNs determined to be qualified to do so. However, the qualifications were not clearly set forth and some of the RNs who conducted those MSEs had not met the qualifications.
* There was a lack of assurance that staff did or said nothing to dissuade patients from staying at the hospital to be evaluated for an EMC and for stabilizing treatment, including inquiring about insurance status.

Findings include:

1. a. The hospital's policy and procedure titled "Emergency Medical Treatment And Labor Act (EMTALA) Compliance For Legacy Health Emergency, Labor And Delivery, Psychiatric Emergency Services And Provider Based Urgent Care Departments; On-Call Licensed Independent Practitioners & Reporting Requirements For Non-Compliance," dated last revised "01/17" was reviewed. It stipulated:
* "This policy sets forth standards for Legacy Health's (Legacy's) use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA)."
* "Dedicated Emergency Departments...include all Legacy Health Emergency, Labor and Delivery...departments."
* "If an individual comes to one of Legacy's Dedicated Emergency Departments, Legacy will provide an appropriate Medical Screening Examination within the capability of the department, including ancillary services routinely available, to determine whether or not an Emergency Medical Condition exists; and...If an individual comes to one of Legacy's Dedicated Emergency Departments Legacy will...Provide to an individual who is determined to have an Emergency Medical Condition such further medical examination and treatment as is required to stabilize the Emergency Medical Condition, or...Arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below."
* "Legacy will not base the provision of emergency services and care upon an individual's...insurance status...or ability to pay for medical services, except to the extent that a circumstance is relevant to the provision of appropriate care."
* "'Appropriate Transfer' means the transferring hospital provides treatment within its capability (defined in terms of the hospital's ability to accommodated the patient, encompassing availability of staff, beds and equipment) that minimize risks with transfer; the receiving facility has agreed to accept transfer; the transferring hospital sends medical records, including the consent to transfer or certification; and the transfer is effected through qualified personnel and transportation equipment...'Capabilities of a medical facility' means that there is physical space, equipment, supplies, and specialized services that the hospital provides...'Capabilities of the staff of a facility' means the level of care that the personnel of the hospital can provide within the training and scope of their professional licenses. This includes coverage available through the hospital's on-call roster...'Capacity' means the ability of the hospital to accommodate the individual requesting examination or treatment of a transferred individual."
* "'Emergency Medical Condition' or 'EMC' means a medical condition manifesting itself by acute symptoms of sufficient severity...such that the absence of immediate medical attention could reasonably be expected to result in...Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy...Serious impairment to bodily functions; or...Serious dysfunction of any bodily organ or part; or...With respect to a pregnant woman who is having contractions...That there is inadequate time to effect a safe transfer to another hospital before delivery; or...That transfer may pose a threat to the health or safety of the woman or the unborn child..."
* "'Labor' means the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in true labor unless a Qualified Medical Person certifies that, after a reasonable time of observation, the woman is in false labor."
* "'Medical Screening Examination' or 'MSE' is a process to determine, with reasonable clinical confidence, whether or not an EMC exists or whether a woman is in labor. The MSE may range from a simple process (such as a brief history and focused physical examination) to a complex process (requiring imaging, laboratory tests and other diagnostic tests or procedures)."
* "'Qualified Medical Person' is an individual qualified to perform the MSE, as approved by the Legacy Board of Directors. MSEs may be performed...In the emergency department by: A Physician...A nurse practitioner who has demonstrated competency through training and skills verification...A physician assistant who has demonstrated competency through training and skills verification...In the Obstetrical Unit by...A registered nurse who has demonstrated competency through training and skills verification...A certified nurse midwife...A physician."
* "...The MSE will be performed by a Qualified Medical Person...The MSE must be the same appropriate screening examination, including ancillary services routinely available to the DED, provided by the DED to any individual coming to the DED or Obstetrical Unit with similar signs and symptoms...Data and information obtained during the MSE shall be recorded in the individual's electronic health record...The MSE will not be delayed in order to obtain insurance or payor information..."
* "...If the patient has an EMC or is in labor...Legacy shall provide, within the capabilities of the staff and facilities available, further examination and treatment required to stabilize the patient's medical condition...If Legacy does not have the capability to provide necessary stabilizing treatment for the patient, Legacy may transfer the patient to another medical facility which has the capability and capacity to provide the required treatment and has accepted the patient. All relevant sections of the Patient Transfer Form must be completed to ensure that the transfer is an Appropriate Transfer...Legacy shall continue to monitor a patient who has or may have an EMC in accordance with the patient's needs until the patient is stabilized, transferred or discharged."
* "...A health record will be opened on all individuals presenting to the emergency department or obstetrics unit. The health record shall include documentation of triage, the MSE, treatment, and discharge/disposition information."
* "Transfer of Unstable Individuals...A decision regarding patient transfer may be made by either patient request or LIP certification...With certification. The individual may be transferred if a LIP or, should a LIP not physically be present at the time of transfer, another Qualified Medical Person in consultation with a LIP, has certified that the medical benefits expected from transfer outweigh the risks....A certification that is signed by a non-LIP Qualified Medical Person shall be countersigned by the responsible LIP within twenty-four (24) hours."
* "When Legacy transfers an individual with an unstabilized EMC to another facility, the transfer shall be carried out in accordance with the following procedures...Legacy shall, within its capability, provide medical treatment that minimizes the risks to the individual's health and, in the case of a woman who is having contractions, the health of the unborn child...A representative of the receiving facility must confirm that...The receiving facility has available space and qualified personnel to treat the individual; and...The receiving facility agrees to accept transfer of the individual and to provide appropriate medical treatment...Legacy must send to the receiving facility copies of all pertinent medical records available at the time of transfer, including...history...records related to the individual's EMC...observations of signs and symptoms...preliminary diagnoses...results of diagnostic studies or telephone reports of the studies...treatment provided...results of any tests...the written patient consent or LIP certification to transfer...the name and address of any on-call LIP who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment...Legacy must forward relevant records, pending lab work and test results to the receiving facility that was not available at the time of transfer as soon as possible...The transfer must be affected through appropriately trained professionals and transportation equipment, including the use of necessary and medically appropriate life support measures during the transfer. The LIP is responsibly for determining the appropriate mode of transport, equipment, and transporting professionals to be used for the transfer."

The policy and procedure failed to ensure the following:
* That appropriate qualifications for RNs who conducted OB MSEs were clearly set forth and defined.
* Under what circumstances or routine would OB RNs conduct MSEs versus a certified midwife versus a physician.
* The policy reflected "Legacy will not base the provision of emergency services and care upon an individual's...insurance status...or ability to pay for medical services, except to the extent that a circumstance is relevant to the provision of appropriate care." There was no further information that reflected what this exception and "circumstances" entailed. There was a lack of assurance that if an individual comes to the hospital for emergency services, the hospital would provide the services required under EMTALA without regard for the individual's insurance status.

b. The policy and procedure titled "Obstetrical Patients in the Emergency Department, Care Of," dated last reviewed "Apr 2018" was reviewed. It stipulated:
* "Purpose...To supplement professional judgment when managing pregnant patients who present to the ED...To coordinate ED and Obstetrical care of pregnant woman and fetus...To support compliance with EMTALA."
* "...Pregnant patients 20.0 gestational weeks or more, with presenting problem and condition related to pregnancy...will be managed on (sic) the L&D Department in most cases...ED RN collaborates with the OB RN about timing and plans to move the patient to L&D...On (sic) L&D, care follows usual practices, including pregnancy related medical screening exam (MSE) and notifying the OB LIP of exam findings."

The policy and procedure failed to ensure the following:
* That appropriate qualifications for RNs who conducted OB MSEs were clearly set forth and defined.
* Under what circumstances or routine would OB RNs conduct MSEs versus a certified midwife versus a physician.
* An assurance that if an individual comes to the hospital for emergency services, the hospital would provide the services required under EMTALA without regard for the individual's insurance status.

c. The policy and procedure titled "Obstetrical Outpatient/Observation Patients in Women's Services Units," dated last reviewed "Jan 2018" was reviewed. It stipulated:
* "Key Point: The steps in the obstetrical outpatient setting assessment and communication process constitute the elements of the Medical Screening Examination."
* "...Red Triggers (Need 1 sustained Red Trigger to activate the MEWT Algorithm)..."
- "Systolic blood pressure greater than or equal to 160..."
- "Nurse clinically uncomfortable with the patient's status..."
* "If the patient MEETS abnormal vital signs or nursing assessments per MEWT guidelines (...one Red Trigger), repeat a full set of vital signs and assessment in 15 minutes..."
* " If the systolic BP is greater than or equal to 160...repeat in 15 minutes. If BP remains at or greater...notify provider immediately."
* "Provide for reassessment of vitals signs...and relevant body system as warranted by patient condition and nursing clinical assessment...Document assessment findings."
* " KeyPoint: (sic) If patient needs to be transferred to another facility...A transfer form must be completed in all cases."

The policy and procedure failed to ensure the following:
* That appropriate qualifications for RNs who conducted OB MSEs were clearly set forth and defined.
* Under what circumstances or routine would OB RNs conduct MSEs versus a certified midwife versus a physician.
* An assurance that if an individual comes to the hospital for emergency services, the hospital would provide the services required under EMTALA without regard for the individual's insurance status.

d. The "Legacy Good Samaritan Hospital And Medical Center Medical Staff Rules and Regulations," dated "Updated December 17, 2017" was reviewed. It stipulated:
* "Responsibility For Medical Care...Medical screening examination of patients who present to OB Departments to determine whether the patient is in active labor may be performed by a registered nurse who has demonstrated competency through training and skills verification, a certified nurse midwife or physician."

The rules and regulations failed to ensure the following:
* That appropriate qualifications for RNs who conducted OB MSEs were clearly set forth and defined.
* Under what circumstances or routine would OB RNs conduct MSEs versus a certified midwife versus a physician.
* An assurance that if an individual comes to the hospital for emergency services, the hospital would provide the services required under EMTALA without regard for the individual's insurance status.

2. The medical record of a pregnant Patient 4 reflected he/she arrived at the OB department by wheelchair on 10/03/2019 at 2235 with a chief complaint of contractions.
* At 2240 documentation by OB RN1 reflected the patient's "Contraction Frequency" was "often."
* At 2243 documentation by OB RN1 reflected "Pulse 54...BP (!) 164/90."
* At 2302 documentation by OB RN1 reflected "Pulse 52...BP (!) 164/90...[Patient]...states [he/she] has had 3 previous vaginal deliveries w/o any difficulties. legs are swollen...states [he/she] has not had a VE this pregnancy - [he/she] thinks that [he/she] is GBS negative but no labs are available at this time."
* At 2305 documentation by OB RN1 reflected "Dilation 3...Effacement (%) 60...[Station] -2...Cervical Characteristics Medium..."
* At 2310 documentation by OB RN1 reflected "[LGSMC OB Physician] notified of pt c/o and findings - [he/she] will confer w/ kaiser to set up a plan."
* At 2330 documentation by OB RN1 reflected "Contraction Frequency 1 - 10...Contraction Duration...65 - 100...Contraction Count per 10 min...2 min...Contraction Intensity Mild...still talking thru (sic) UC's"

* At 2335 documentation by OB RN2 reflected the patient's blood pressure had increased to "BP (!) 164/97," and reflected "...Pain Intensity 7 [on a scale of 1 - 10]...Location Abdomen...Pain Orientation Lower...Pain Description/Quality Cramping...Altered Mental Status Yes...Nurse clinically uncomfortable with patient status Yes"
* At 2338 OB RN2 documented "Cough Dry;Non-Productive...Edema...Right Lower Extremity +4; Pitting; Ankle; Pedal; Midcalf; Below knee. Left Lower Extremity +4; Below knee; Ankle; Pedal...Level of Consciousness Alert...Visual Disturbance Blurred..."

* At 0000 documentation by OB RN1 reflected "...Uterine Activity...Contraction Frequency 3-8...Contraction Duration 45-95...Contraction Count per 10 min 2 min...Contraction Intensity Moderate..."
* On 10/04/2019 at 0010 documentation by OB RN1 reflected "Cervical Exam...Dilation 3...Effacement (%) 60...[Station] -2...Cervical Characteristics Medium...Presentation Cephalic..."
* At 0014 documentation by OB RN1 reflected "discharge instru (sic) reviewed w/ pt - instr (sic) to go directly to Kaiser Sunnyside - informed that they are expecting [him/her] there. Pt states [he/she] feels comfortable going to Kaiser with [his/her] [significant other] driving. Pt [significant other] states [he/she] knows where Sunnyside hospital is and knows where the labor area is"
* At 0016 documentation by OB RN1 reflected "pt discharged to go to sunnyside Kaiser per care (sic)."

The record contained an AVS report that reflected it was printed by OB RN1 on 10/04/2019 "12:00 AM." The AVS report reflected:
- "Condition at Discharge Discharge Condition: Fair"
- "Activity After Discharge As tolerated."
- "...Call your doctor or midwife for any of these reasons...Baby is not moving as often as usual...Headache that won't go away...Constant abdominal (belly) pain...Blurry vision or spots in front of your eyes...Sudden increase in swelling, especially your face and hands...Bright red bleeding from your vagina...Fever..."
- "OB Follow-up Instructions: Please go to Kaiser Sunnyside hospital OB department when you leave here - they are expecting you. If you have questions, please call your provider. Your hospital phone number is [phone number]."
- "Discharge Instructions...The main reason you were in the hospital was: Labor check - not in labor - has Kaiser insurance and needs evaluated by Kaiser Labor and delivery..."
No other discharge instructions were provided.

* An H&P electronically signed by LGSMC OB Physician on 10/04/2019 at 1847 with a "Date of Service" of 10/04/2019 at 0016 reflected:
- "10/4/2019 6:13 PM Labor and Delivery Triage Evaluation Late Entry"
- "Subjective: [Patient] is...39 [weeks] 3 [days] who presents to Labor and Delivery Triage for contractions that [he/she] reports as starting around noon on 10/3/19. [He/she] reports no loss of fluid. No Vaginal bleeding. Baby is moving normally. [He/she] is able to talk through contractions and is [his/her] own historian. [He/she] arrives with [significant other], who drove [him/her] in private car, and [his/her] kids. Phone call from RN at 2302 to report that the patient had arrived complaining of labor. Per charge RN, the patient has [his/her] insurance card and it shows [he/she] has Kaiser insurance. Charge RN asked patient why [he/she] did not go to a Kaiser hospital. Patient replies that [he/she] spoke with advice nurse earlier who told [him/her] that [he/she] could go to any hospital...Reports the patient rates [his/her] pain 7/10, but that [he/she] is able to talk through [his/her] contractions. [His/her] blood pressure is elevated."
- "Objective...General: Not examined...Cervical Exam per Charge RN exam: 2-3 cm dilated, 30 effaced, -3 station, cervical position mid, presenting part vertex...Uterine contractions: irregular Membrane status: intact"
- "Assessment...at term with spontaneous onset of contractions. [He/she] appears to be in early labor. Blood pressure is elevated in the severe range, so there is not an option to send [him/her] home. [His/her] insurance is listed as Kaiser, which the charge nurse wants to stress to me requires a call to Kaiser because they prefer to take care of their patients if an emergency is not occurring."
- "Plan: Charge RN has already spoken to patient to explain that generally Kaiser will work to get their own patients transferred to a Kaiser facility if this is safe. This has also been my experience since 1999, so I will call Kaiser to arrange for direct discharge and direct admission to Kaiser. Patient is stable right now."

* Progress Notes electronically signed by LGSMC OB Physician on 10/04/2019 at 1921 with a "Date of Service" of 10/04/2019 at 0016 reflected:
- "10/4/2019 6:53 PM Labor and Delivery Triage Evaluation Conversation with Kaiser team (late entry)."
- "Chief Complaint: contractions; elevated blood pressure."
- "Subjective: [Patient] presents to Labor and Delivery Triage for contractions, but more importantly noted to have blood pressure with systolic 164 and diastolic 97. Spoke with...[KSMC Physician]...Advised [KSMC Physician] that my experience was that we try to get Kaiser patients to a Kaiser facility. Explained the patient was not in labor, but that I could not discharge [him/her] to home because [his/her] blood pressure was elevated. [His/her] response was that I needed to make sure the patient is stable. I replied that the patient is stable. Only outlier is the severe range blood pressure, but that I don't want to start a full work up because I think [he/she] should be transferred to Kaiser. [KSMC Physician] then told me that I had no idea if the patient was stable and that I could not transfer [him/her] until I did a full work up. I explained that this was the only option for transfer, as if I wait for a full work up the patient will likely be too far in labor to safely transfer. [KSMC Physician] then became angry, shouting at me that I can't transfer an unstable patient. I decided the conversation was not evolving and gently terminated the call."
- "When I called back to labor and delivery I was told the patient was...getting dressed to leave. [He/she] felt once [he/she] knew [he/she] should be at a Kaiser facility [he/she] wanted to proceed directly to minimize risk. I asked the charge nurse to be certain the patient knew [he/she] had hypertension so needed to go directly to Sunnyside..."
- "Assessment: Early labor with new findings of severe elevation of systolic blood pressure. Consider pre eclampsia...Drug use...Chronic hypertension (less likely)"
- "Plan: Spoke with team at Kaiser, who are not willing to discuss beyond declaring I have not confirmed the patient is stable. Spoke with patient, and with the 'transfer MD,' both under the belief that if a person has 'Kaiser OHP' they can 'be seen anywhere'...the patient desires discharge now that [he/she] knows [he/she] may have an insurance issue...[he/she] will leave now and go to Sunnyside. [He/she] understands that we have instructed [him/her] to go straight there. Kaiser did not offer an ambulance for transfer...so I'll let [him/her] go directly to Sunnyside by private car. [He/she] has expressed understanding to my charge nurse that [he/she] needs to go directly, because there is a risk of worsening blood pressures. [He/she] understands the risk of staying is that [his/her] insurance may not cover [his/her] care..."
- "Was discharged from [LGSMC] 1214am."

* The "Discharge Information" reflected:
- "Discharge Date/Time...10/04/2019 0016"
- "Discharge Destination...Other"

*Review of the physician orders under "All Orders - Detailed" reflected no orders for stabilizing treatment, including but not limited to treatment of the patient's contractions, increasing blood pressure, visual disturbance, edema, possible pre-eclampsia and abdominal pain. The orders were primarily related to discharge and were comprised of the following:
-"Discharge Condition: Fair ..." The order was electronically signed by the LGSMC OB Physician and dated 10/04/2019 at 0714.
-"The main reason you were in the hospital was ...Order comments: Labor check ..." The order was electronically signed by the LGSMC OB Physician and dated 10/04/2019 at 0714.
-"Discharge Undelivered ..." The order was electronically signed by the LGSMC OB Physician and dated 10/04/2019 at 0714.
-"Call you doctor or midwife for any of these reasons..." The order was electronically signed by the LGSMC OB Physician and dated 10/04/2019 at 0714.
-"OB Follow-up Instructions ...Order comments: Please go to Kaiser Sunnyside hospital OB department when you leave here ..." The order was electronically signed by the LGSMC OB Physician and dated 10/04/2019 at 0714.
-"As tolerated ...Patient Activity ..."The order was electronically signed by the LGSMC OB Physician and dated 10/04/2019 at 0714.
-"Discharge Patient ..." The order was electronically signed by the LGSMC OB Physician and dated 10/04/2019 at 0714.

The record was unclear, inconsistent and lacked documentation that reflected an MSE was conducted within the capabilities of the hospital by qualified staff and in accordance with hospital policies and procedures. For example:
- OB RN1 and OB RN2 were not qualified to conduct MSEs as identified in finding 5 below.
- There was no documentation that reflected the LGSMC OB Physician, or any other LIP examined the patient. This was confirmed with the FBC ANM at the time of the record review on 10/10/2019 at 1445.
- Although the record reflected the patient's blood pressure was described as "severe elevation of systolic blood pressure" with a blood pressure reading of "(!) 164/97" on 10/03/2019 at 2335, there was no reevaluation of the patient's blood pressure prior to departure on 10/04/2019 at 0016, 40 minutes later. This was confirmed with the FBC ANM at the time of the record review on 10/10/2019 at 1445.
- Documentation by the RN at 2335 reflected "Pain Intensity 7 [on a scale of 1 - 10]...Location Abdomen..." There was no reevaluation of the patient's pain intensity prior to departure.
- Documentation by the RN at 2335 reflected "...Altered Mental Status Yes...Nurse clinically uncomfortable with patient status Yes" and at 2338 the RN documented "...Level of Consciousness Alert..." There was no reevaluation of the patient's altered mental status prior to departure.
- Documentation by the RN at 2338 reflected "Visual Disturbance Blurred..." There was no reevaluation of the patient's visual disturbance prior to departure.
- The LGSMC OB Physician documented in a late entry Progress Notes with "Date of Service" 10/04/2019 at 0016 "the patient was not in labor." However, in the same Progress Notes with "Date of Service" 10/04/2019 at 0016, the LGSMC OB Physician documented "Assessment: Early labor..." and in an H&P late entry with "Date of Service" of 10/04/2019 at 0016 the LGSMC OB Physician documented "[Patient] appears to be in early labor..." There was no documentation that reflected the patient was in false labor.

The medical record reflected the following components of an appropriate transfer were not arranged and carried out. Examples included:
* The AVS report printed on 10/04/2019 at "12:00 AM" reflected "...go to Kaiser Sunnyside hospital OB department when you leave here - they are expecting you." However, there was no documentation that reflected who at the receiving facility was "expecting" the patient. There was no documentation that reflected the receiving facility had agreed to accept the patient in transfer and had capability and capacity to care for the patient and unborn child.
* There was no physician certification of risks and benefits of transfer.
* There was no transfer form as required by hospital policy.
* The LGSMC OB Physician documentation reflected "patient desires discharge now that [he/she] knows [he/she] may have an insurance issue..." The documentation reflected the patient "desired" to be discharged only after staff engaged in discussions with him/her about insurance status.
* There was no documentation that reflected the patient requested to be transferred prior to staff discussions with him/her about insurance, and was subsequently informed of the risks of transfer and the hospital's EMTALA obligation to arrange an appropriate transfer.
* There was no documentation that reflected the patient refused an appropriate transfer and was subsequently informed of the risks of refusal and the hospital's EMTALA obligation to arrange an appropriate transfer.
* There was no documentation that reflected medical records were sent to the receiving facility.
There was no documentation that reflected an appropriate transfer was arranged as required, that included qualified personnel and transportation equipment, including the use of necessary and medically appropriate life support measures during the transfer. The medical record reflected the patient who was was pregnant and experiencing contractions, had severe range blood pressure with risk of worsening blood pressures, visual disturbances, altered mental status, and pedal edema was "discharged" and told by hospital staff to go directly to KSMC by private vehicle with a significant other as a result of his/her insurance.

3. An interview was conducted with the FBC ANM at the time of the medical record review on 10/10/2019 at 1445. He/she provided the following information:
* The FBC ANM stated OB RN1 and OB RN2 conducted the MSE for Patient 4 and no other RNs conducted any part of the MSE.
* The FBC ANM stated the LGSMC OB Physician did not conduct any part of the MSE, nor did any other LIP. The FBC ANM stated "[LGSMC OB Physician] did not evaluate the patient or see the patient at all."
* The FBC ANM confirmed there was no documentation in the medical record that reflected certification of risks and benefits of transfer. The FBC ANM stated "I did not find any transfer documentation or paperwork from the physician."
* The FBC ANM confirmed there was no documentation in the medical record that reflected medical records were sent to the receiving facility.
* The FBC ANM confirmed there was no documentation in the medical record that reflected a KSMC physician accepted the patient for transfer. The FBC ANM stated "[LGSMC OB Physician] did not get acceptance from the Kaiser physician for this patient."
* The FBC ANM stated the medical record reflected the patient was 39 weeks pregnant, was having contractions, was in "early" labor, and had not been evaluated and determined to be in "false labor."
* The FBC ANM confirmed the medical record reflected the patient was transported by private vehicle with a significant other to KSMC. The FBC ANM stated the expectation for a patient who is in labor is that they take medical transportation if they are transferred to another hospital. However, this did not occur as the FBC ANM confirmed the patient was transported by private vehicle.

4. During interview with the FBC NM on 10/10/2019 at 1210 he/she confirmed that LGSMC had capability and capacity to care for Patient 4 and provide further evaluation and stabilizing treatment on 10/03/2019 and 10/04/2019.

5. a. Regarding staff qualifications to conduct MSEs:
During an interview with FBC NM, FBC ANM and CNS on 10/11/2019 at 1045, it was stated that RNs who worked in the OB unit conducted MSEs of pregnant patients. The following information was provided in response to a request for the process the hospital used to qualify OB RNs to conduct MSEs:
* The FBC ANM and CNS stated that the following training and competencies were required to be completed for OB RNs who conducted MSEs:
- Orientation to the OB unit.
- Work with a preceptor for an evaluation period.
- Completion of the "Antepartum and Triage: Evaluates components of the medical screening exam" sections on the "Women's Services Competency Validation Tool."
- In addition to the above orientation and competencies, new OB nurses were required to attend a seven-day perinatal collaborative course.
* The CNS stated there was nothing documented that reflected the process and specific training and competencies that the hospital used to qualify OB RNs to conduct MSEs.

b. The following documents were provided in response to a request for the training and competency documents the hospital used to qualify RNs to conduct MSEs:
* An 11-page document titled "Women's Services Competency Validation Tool" (referenced above) dated "2018" that included the following competencies:
- "Evaluates components of the medical screening exam...Maternal VS...Frequency and duration of contractions...Documentation of fetal well-being...Cervical dilation and effacement (unless contraindicated)...Fetal presentation and station...Status of membranes...Date and time of arrival...time of notification of provider..."

c. Review of staff training records for OB RN1 reflected the hospital's policies related to MSEs were not carried out as OB RN1 had not completed the training and competencies required to conduct MSEs. OB RN1's training records reflected:
* No documentation of the required "Women's Services Competency Validation Tool" sections under "Antepartum and Triage: Evaluates components of the medical screening exam" including but not limited to the following competencies: "Maternal VS...Cervical dilation and effacement (unless contraindicated)...Fetal presentation...Date and time of arrival...Time of notification of provider."

There was no docume

Based on interview, review of documentation in the medical records of 2 of 8 patients who were transferred to other hospitals (Patients 1 and 4), including Patient 4 who was 39 weeks pregnant and having contractions and "severe range" blood pressure, review of medical staff rules and regulations, review of hospital policies and procedures, review of staff training records, and review of event report documentation, it was determined that the hospital failed to fully develop and enforce clear and complete EMTALA policies and procedures to ensure that within the capabilities of the staff and facilities available at the hospital, it provided for further medical examination and treatment as required to stabilize the patients' medical conditions.
* Patient 4 was directed by hospital staff to go to another hospital by private vehicle with a significant other for further examination and treatment where the hospital had the capability and capacity to provide the further examination and treatment. The patient was transferred because of insurance coverage.
* Patient 1 had a cardiac condition and was transferred to another hospital for further examination and treatment where the hospital had the capability and capacity to provide the further examination and treatment. The patient was transferred because of insurance coverage.

Findings reflected:

1. Refer to the findings under Tag A2406 related to the hospital's failure to provide stabilizing treatment within its capabilities and capacity for Patient 4 who was 39 weeks pregnant, was experiencing contractions, "severe range" blood pressure, visual disturbance, edema, and possible pre-eclampsia. The hospital failed to provide the patient stabilizing treatment for these medical conditions and instead told the patient to go to another hospital by private vehicle with a significant other because of the patient's insurance status.

2. Refer to the findings under Tag A2409 related to the hospital's failure to provide stabilizing treatment within its capabilities and capacity for Patient 1 who had a cardiac condition. The hospital failed to provide the patient examination and treatment necessary to stabilize the medical condition within the capabilities of the staff and facilities available at the hospital and instead transferred the patient because of the patient's insurance coverage.









40575

Based on interview, review of documentation in the medical record 7 of 8 medical records of patients who were transferred to other hospitals (Patients 1, 2, 3, 14, 15 and 16), or were "discharged" and told by hospital staff to go directly to another hospital (Patient 4), review of medical staff rules and regulations, review of policies and procedures, review of staff training records, and review of event report documentation, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure that it affected appropriate transfers for patients for whom an EMC had not been ruled out, removed or resolved:
* Regarding Patient 4:
The hospital failed to provide stabilizing treatment to the patient who was 39 weeks pregnant and experiencing contractions and "severe range" blood pressure before discharging the patient and instructing him/her to go directly to another hospital by private vehicle with a significant other during night hours for insurance reasons when the hospital had capability and capacity to admit the patient.
- The receiving hospital had not accepted the patient due to the patient's instability.
- Physician certification of medical benefits and risks were not documented for the patient.
- Medical records were not sent to the receiving facility for the patient.
- A Transfer Form was not completed for the patient as required by hospital policy.

This situation created an imminent risk of the likelihood of harm to this patient and the unborn child, and harm to other patients.

In addition:
* Regarding Patients 1, 2, 3, 14, 15, and 16 the risks of transfer were not individual or patient specific.
* Regarding Patient 1, the patient was transferred for further examination and/or treatment of a cardiac condition where LGSMC had the capability and capacity to provide the further examination and/or treatment.

Findings include:

1. Refer to the findings identified under Tag A2406 that reflects the hospital's failure to affect an appropriate transfer for Patient 4:
* The patient was 39 weeks pregnant and was experiencing contractions, "severe range" blood pressure, visual disturbance, edema, and possible pre-eclampsia.
* The hospital staff directed the pregnant patient to go directly to another hospital by private vehicle with a significant other because of the patient's insurance status.
* The receiving facility had not accepted the patient for transfer because of the patient's instability.
* There was no physician certification of risks and benefits of transfer for the patient.
* There were no medical records sent to the receiving facility.
* There was no transfer form as required by hospital policy.

2. a. The medical record of Patient 1 reflected he/she arrived to the ED by ambulance on 04/01/2019 at 0358 with an "Arrival Complaint" of chest pain.
* The "ED Arrival Information" reflected "Acuity...2-Emergency."
* "All Flowsheet Data" documentation on 04/01/2019 at 0410 reflected "Cardiovascular...Pt reports CP since yesterday with this morning pain now radiating to [his/her] back. Pt hx of PE and [states] feels similar to [his/her] last episode."
* "All Flowsheet Data" documentation on 04/01/2019 at 0433 reflected "BP 126/91...Pulse 96...O2 Flow Rate...2 l/min...NC"
* "All Flowsheet Data" documentation on 04/01/2019 at 0530 reflected "BP 138/100...Pulse 93..."
* The record reflected a MSE was conducted and included labs, EKG and chest X-ray.
* ED Provider Notes electronically signed by the physician on 10/01/2019 at 0533 reflected:
- "...[male/female] hx of afib (sic) anticoagulated on warfarin, HTN...pw chest pain that began yesterday. Patient endorses sharp pain in the substernal region with radiation into [his/her] upper back that is worse with inspiration...woke up with the pain yesterday and has been present ever since. EMS administered nitroglycerin without change in pain...had more relief with fentanyl. Persistent moderate pain presently.
* "Review of Systems...Respiratory: Positive for shortness of breath...Cardiovascular: Positive for chest pain..."
* "Differential diagnosis considered would include acute coronary syndrome, arrhythmia, PE, dissection, gastritis...Labs reviewed...Chemistry notable for BUN of 31 and creatinine of 1.49 with a glucose of 155. Initial troponin is negative. INR is therapeutic...D-dimer is negative."
* "Physical Exam...BP 142/98...Pulse 103...Spo2 93%...Heart: irregularly irregular..."
* Hospitalization is indicated given ongoing chest pain with history of atrial fibrillation...Dissection seems unlikely...but should continue to be considered...5:23 AM...Kaiser will accept pt for Sunnyside ED."
* "Diagnosis and Disposition...Chest pain in adult...Atrial fibrillation with RVR..."
* "Disposition: Transfer to Kaiser Hospital to ED"

The record reflected the patient was transferred by ambulance to KSMC ED on 04/01/2019 at 0553.

* The "Patient Transfer" form signed by the physician and dated 04/01/2019 reflected:
-The "Provider Certification" section reflected "Based on the information available at the time of transfer and based on the reasonable risk and benefits to the patient...I certify that the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risk...to the individual's medical condition from being transferred."
-The Benefits of the transfer were identified as "Kaiser coverage" and "Health insurance coverage will be better at receiving hospital."

-The "Risks" of the transfer were identified as "Instability...Unanticipated worsening of condition during transport...Potential for accidents or traffic delays during transport"
-The "Transfer Demand" section of the form contained language for a patient to sign to indicate that they requested and insisted on a transfer to another hospital. That section was blank.

There was no documentation in the transfer form or elsewhere in the record that reflected patient specific individual risks of transfer had been identified.

There was no documentation that reflected an EMC had been ruled out, removed or resolved or that LGSMC transferred the patient because it lacked available capabilities of the staff and/or facilities, for further examination and treatment as required to stabilize the patient's medical condition. The only benefits of transfer that were identified were "Kaiser coverage" and "Health insurance coverage will be better at receiving hospital."

b. During an interview with the ED ANM and ED NM on 10/10/2019 at 1325 regarding Patient 1, they stated:
* The patient was transferred to KSMC ED for further evaluation and treatment of his/her medical condition of chest pain.
* The hospital had capability and capacity to further evaluate and treat the patient's medical condition.
* The patient was transferred because he/she had Kaiser insurance and not because the hospital lacked the capability and capacity to further evaluate and treat the patient's medical condition.
* The ED NM confirmed the record lacked documentation of patient specific individual risks of transfer.

3. a. The ED record for Patient 2 reflected that he/she presented to the ED on 05/08/2019 at 2341 with a chief complaint of "suicidal." The medical record reflected:
* The patient was triaged and had an MSE that determined he/she needed to be transferred to a hospital for psychiatric services that were not available at LGSMC.
* On 05/09/2019 the MD signed the "Patient Transfer" form that included the physician certification of risks and benefits of transfer under which the "Benefits" were identified as "[psych]" and "Higher level of service at receiving hospital." The "Risks" were identified as "MVA," "Unanticipated worsening of condition during transport" and "Potential for accidents or traffic delays during transport." The "Reason For Transfer" reflected "SI."
* The record reflected the patient was transferred by secure transport to LEMC Unity Center for Behavioral Health on 05/09/2019.
There was no documentation of patient specific individual risks of transfer on the transfer form or elsewhere in the record.

b. The medical record of Patient 2 was reviewed with the ED ANM on 10/10/2019 at 1320 and he/she confirmed the record contained no further documentation of the risks of transfer.

4. a. The ED record for Patient 3 reflected he/she presented to the ED on 06/25/2019 at 2200 with a chief complaint of "AMS-Adult, Aggressive Behavior." The medical record reflected:
* The patient was triaged and had an MSE that determined he/she needed to be transferred to another hospital for psychiatric services that were not available at LGSMC.
* On 06/26/2019 the MD signed the "Patient Transfer" form that included the physician certification of risks and benefits of transfer. The "Benefits" were identified as "mental health care and stabilization" and "Higher level of service at receiving hospital." The "Risks" were identified as "worsening of condition, "Unanticipated worsening of condition during transport" and "Potential for accidents or traffic delays during transport." The "Reason For Transfer" reflected "Unity - [Inpatient] Psych Care."
* The record reflected the patient was transferred by secure transport to LEMC Unity Center for Behavioral Health on 06/26/2019.
There was no documentation of patient specific individual risks of transfer on the transfer form or elsewhere in the record.

b. The medical record of Patient 3 was reviewed with the ED ANM on 10/10/2019 at 1345 and he/she confirmed the record contained no further documentation of the risks of transfer.

5. The ED record for Patient 14 reflected he/she presented to the ED on 10/02/2019 at 1027 with a chief complaint of "toe pain/SI." The medical record reflected:
* The patient was triaged and had an MSE that determined he/she needed to be transferred to a hospital for psychiatric services that were not available at LGSMC.
* The "Social Work" notes dated 10/02/2019 at 1901 reflected "Discussed with ED provider. Given...recent 4 day custody and current concern for psychosis and SI, plan is to refer Pt to Unity [Psychiatric Emergency Services] for further assessment...safety and stabilization..."
* On 10/02/2019 the MD signed the "Patient Transfer" form that included the physician certification of risks and benefits of transfer. The "Benefits" were reflected as "higher level of care" and "Higher level of service at receiving hospital."
The "Risks" were reflected as "MVC, decompensation en route," "Unanticipated worsening of condition during transport" and "Potential for accidents or traffic delays during transport." The "Reason For Transfer" reflected "Higher level of care."
* The record reflected the patient was transferred to LEMC Unity Center for Behavioral Health on 10/02/2019.
There was no documentation of patient specific individual risks of transfer on the transfer form or elsewhere in the record.

6. The ED record for Patient 15 reflected he/she presented to the ED on 08/17/2019 at 2235 with a chief complaint of "Psychiatric Problem." The medical record reflected:
* The patient was triaged and had an MSE that determined he/she needed to be transferred to a hospital for psychiatric services that were not available at LGSMC.
* On 08/18/2019 the MD signed the "Patient Transfer" form that included the physician certification of risks and benefits of transfer.
The "Benefits" were identified as "mental health care" and "Appropriate bed space not available here." The "Risks" were identified as "car accident," "Unanticipated worsening of condition during transport" and "Potential for accidents or traffic delays during transport." The "Reason For Transfer" reflected "mental health bed."
* The record reflected the patient was transferred to LEMC Unity Center for Behavioral Health by secure transport on 08/18/2019.
There was no documentation of patient specific individual risks of transfer on the transfer form or elsewhere in the record.

7. The ED record for Patient 16 reflected he/she presented to the ED on 07/25/2019 at 1008 with a chief complaint of "Anxiety." The medical record reflected:
* The patient was triaged and had an MSE that determined he/she needed to be transferred to a hospital for psychiatric services that were not available at LGSMC.
* The "Social Work" notes dated 07/25/2019 at 1206 reflected "Pt...presents to LGSMC ED reporting [he/she] is having a 'nervous breakdown'...feeling hopeless with some SI...Pt presents as paranoid and delusional...Pt was seen at LEMC ED earlier this morning with similar presentation and eloped from ED...[Social Worker] will look towards transferring Pt to Unity..."
* On 07/29/2019 the MD signed the "Patient Transfer" form that included the physician certification of risks and benefits of transfer. The "Benefits" were identified as "Higher level of care (psych facility)," "Higher level of service at receiving hospital" and "Appropriate bed space not available here." The "Risks" were identified as "Decomp during transfer," "Unanticipated worsening of condition during transport" and "Potential for accidents or traffic delays during transport."
The "Reason For Transfer" reflected "Higher level of care."
* The record reflected the patient was transferred to LEMC Unity Center for Behavioral Health on 07/29/2019.
There was no documentation of patient specific individual risks of transfer on the transfer form or elsewhere in the record.






40575