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Based on policy review and interview, the facility failed to follow their provider agreement to ensure policies and procedures were developed and implemented to reflect current Emergency Medical Treatment and Active Labor Act (EMTALA) practice. This deficient practice has the potential to adversely affect all patients coming to the Emergency Department for services.

Findings Include:

Review of the document titled "Mid-Level Practice Protocol" effective 08/29/19 showed, ...3. Medical Coverage: Emergency Department: Upon the patient's arrival at the Emergency Room, the Physician Assistant [PA]/Nurse Practitioner [NP] shall evaluate the patient and may elect to determine management and treatment options where routine medical problems are involved. The PA/NP may call either the patient's personal physician or the on-call physician to discuss management and treatment options. The PA/NP shall then manage the case in accordance with the physician's orders. If the PA/NP does not feel comfortable with the patient's condition, the patient's physician or on-call physician shall personally evaluate the patient or make arrangement for the appropriate specialist to do so. In case of a life-threatening emergency, the PA/NP shall do whatever PA/NP is reasonably capable of doing to preserve the patient's life until the physician arrives. In cases of true emergencies, the physician shall be notified as soon as the seriousness of the condition is recognized.

Review of a closed medical record showed patient # 1, who had multiple medical problems including high blood pressure, uncontrolled diabetes, chemotherapy for breast cancer, chronic obstructive pulmonary disease, and heart disease presented to the ED by ambulance on 1/23/19 at 9:37 PM after becoming weak and falling at home. Documentation in the medical record showed that physician assistant H examined patient #1 and documented her diagnoses included pneumonia, sepsis and acute renal failure (an emergency medical condition). Physician assistant H documented he discussed the patient with on-call physician B and C at 11:37 PM. Further documentation showed that physician assistant H contacted a critical access hospital providing a lower level of care to arrange a transfer because the patient "Has been terminated from Pratt County Doctors Practices." The medical record did not contain evidence that on-call physician B or C came to the ED to provide further examination or stabilizing treatment for the patient's emergency medical condition.

Review of a closed medical record showed patient # 3 presented to the ED on 1/27/19 at 7:56 AM concerned that she was having a heart attack. Documentation in the medical record showed that physician assistant H examined patient # 3 and determined she was having a heart attack (an emergency medical condition). Documentation on the "EMTALA PLUS FORM" showed that physician assistant H determined the patient required transfer to another hospital for treatment to stabilize her emergency at 10:00 AM, two hours after presenting to the ED. At 10:05 AM, documentation showed that physician assistant H discussed the patient with on-call physician C. The medical record did not contain evidence that on-call physician C came to the ED to provide further examination of the patient's emergency medical condition. The patient remained in the ED for approximately 2 hours and 40 minutes prior to transfer to Hospital B.

Review of a closed medical record showed patient # 22 presented to the ED by ambulance on 8/7/19 at 4:01 AM complaining of weakness, shortness of breath and had an extremely low blood pressure 80/51 (normal range 120/80 - 140/90). Documentation in the medical record showed that physician assistant J examined patient # 22 and reviewed the lab blood tests results (arterial blood gas) performed at 4:45 AM which showed that patient # 22 was in respiratory distress. At 5:40 AM physician assistant J noted that patient # 22 had an elevated potassium level of 6.3 (normal range 3.4 - 5.3). An elevated potassium can be life threatening. At 5:35 AM the ED nurse documented in the nursing notes that patient # 22 complained of chest pain, "states it feels like an elephant sitting on his chest." At 5:45 AM the nurse documented that the patient kept stating "Help me, I need help, I'm having chest pain." At 6:15 AM documentation on the "Code Blue Form" showed that patient # 22's heart stopped beating and staff initiated cardio-pulmonary resuscitation twice between 6:15 AM and 7:08 AM. The medical record did not contain evidence that on-call physician F came to the ED to further evaluate or manage the patient's life-threatening emergency. The patient remained in the ED for approximately 3 hours and 40 minutes prior to transfer to Hospital B in an unstabilized emergency medical condition. Review of a second medical record showed that the ambulance transporting patient # 22 returned to the ED at 8:02 AM, approximately twenty minutes after departure because the patient's heart stopped beating. Documentation on the "Code Blue Form" showed that ED staff administered medications, rechecked the patient's blood pressure which remained significantly low at 88/62, and directed the ambulance to continue transport to hospital B. The medical record did not contain evidence that on-call physician F was notified or came to the ED to determine whether admission to the intensive care unit for further stabilizing treatment prior to transport to Hospital B outweighed the medical risks of transfer.

Refer to tag A2407 for further details.

Review of the policy "EMTALA" effective 04/11/19, showed the following on pages 3 and 4:
"III. Appropriate Discharge or Transfer" ...

"B. Unstabilized person. If the individual is not stabilized, the Hospital will not discharge or transfer the person unless the following conditions are met:" ... "A physician certifies in writing that the benefits of discharge or transfer outweigh the risks (see Patient Transfer or Discharge Form); or If a physician is not physically present, a qualified medical person consults with the physician and certifies in writing that the benefits of discharge of transfer outweigh the risks. The physician must subsequently countersign the certification. (EMTALA Plus Form) ..."

Review of the "EMTALA PLUS FORM" found in the closed medical records for Patients 1, 3, 4, 5, 6, 10, 11, 18, 22, and 24 who were transferred with an unstabilized emergency medical condition, did not show evidence that a qualified medical person (physician assistant or nurse practitioner) consulted with a physician who certified that the medical benefits of transfer exceeded the risks, or countersigned the certification if not physically present in the ED at the time.

During an interview on 11/04/19 at 9:40 AM, Staff M, Director of Emergency Services confirmed that the hospital did not follow the EMTALA requirements, the hospital's policy, or the instructions on the "EMTALA PLUS FORM" requiring a physician to certify that the medical benefits of transfer outweigh the risks or if not physically present in the ED, to countersign their certification documented by the physician assistant or nurse practitioner. The Director of Emergency Services said, "In our ED we only have physician assistants and nurse practitioners." "We don't have any physicians who work in the ED." "We have physicians who take rotating call to cover the ED if needed." Staff M, continued, "It was just recently decided upon, by our medical staff, that they do not have to sign after a midlevel makes a transfer." "They used to sign off on every record post transfer."

Refer to tag A-2409 for further details.

Based on medical record review, staff interview, and policy review, the hospital failed to provide stabilizing treatment using available services within its capabilities for two of 20 patients (Patient 1 and 22) and failed to ensure stabilizing treatment was not delayed from the time of the patient's arrival in the Emergency Department (ED) until the transfer to a receiving hospital for one of 20 patients (Patient 3) with an emergency medical condition. This deficient practice has the potential to adversely affect all patients coming to the emergency department for services and could lead to further complications or death.


Findings Include:

Review of the policy "EMTALA [Emergency Medical Treatment and Active Labor Act]" effective 04/11/19, showed: ... II. Stabilizing Treatment. If the medical screening examination indicates that the person has an emergency medical condition, the Hospital will provide: 1. Treatment (including admission) within the capabilities of the staff and facilities routinely available at the Hospital (including on-call physicians and ancillary services routinely available) as required to stabilize the person before the person is discharged or transferred to another facility ...

Patient # 1

Review of a closed medical record showed patient # 1, who had multiple medical problems including high blood pressure, uncontrolled diabetes, chemotherapy for breast cancer, chronic obstructive pulmonary disease, and heart disease, presented to the ED by ambulance on 1/23/19 at 9:37 PM after becoming weak and falling at home. Documentation in the medical record showed that physician assistant H examined patient #1 and documented that the patient saw a physician earlier in the day who thought she had shingles on her left upper back. Further documentation showed the patient stated she had not been able to take care of things because she has not been feeling well, and that she appeared elderly and frail, in moderate distress. Physician assistant H reviewed patient # 1's blood test results and chest x-ray results between 10:10 - 11:00 PM. At 11:37 PM physician assistant H documented he discussed patient # 1's test results with on-call physician B and C. Further documentation showed patient # 1's diagnoses included pneumonia, sepsis (life threatening infection) and acute renal failure (an emergency medical condition coupled with patient # 1's other medical problems).

At 11:38 PM, physician assistant H documented he discussed patient # 1's case with the on-call physician at a critical access hospital providing a lower level of care and arranged a transfer because the patient "Has been terminated from Pratt County Doctors Practices." The medical record did not contain evidence that on-call physician B or C came to the ED to provide further examination or stabilizing treatment for the patient's emergency medical condition.

Review of the "EMTALA Plus Form" showed Patient 1 was transferred to the receiving critical access hospital on 01/23/19 at 11:35 PM, in an unstable condition, "Pneumonia with Sepsis" and "Acute Renal Failure." The reason for the transfer was documented as, "Medical Admission." The space on the form for the physician's countersignature was blank.

During an interview on 11/05/19 at 9:59 AM, Staff M, Director of Emergency Services stated, "Patient 1 was transferred to another hospital because two of our physicians [Physician B and Physician C] refused to admit her to the facility, because she had been their patient in private practice, and they had both fired her."

During an interview on 11/05/19 at 11:54 AM, Staff H, Physician Assistant (PA) said "[Patient 1] needed to be admitted." "The physicians didn't think they had to admit her here if they had fired her from their practice."

During an interview on 11/06/19 at 9:30 AM, Staff A Medical Director stated that a med-exec [medical executive] meeting was held and the bylaws, rules, and regulation, to outline how to handle unassigned patient [like Patient 1.] were updated. According to current bylaws, Internal Medicine should have admitted her despite her status in the clinical setting.

During an interview on 11/06/19 at 11:45 AM, Staff C, Physician said, "[Patient 1] was the patient that I had fired. As far as I knew, I thought it was okay to not accept a patient for that reason." "Another Physician from the clinic would not have accepted her either." Physician C stated "We would have been able to treat Patient 1 here."

Patient 22

Review of a closed medical record showed that Patient 22 presented to the Emergency Department (ED) by ambulance on 08/07/19 at 4:01 AM complaining of weakness and difficulty breathing. The triage notes in the medical record revealed the patient had been feeling weaker and more short of breath over the past couple of days. Further documentation showed that the ED staff placed the patient on supplemental oxygen at 6 liters and noted he had significant swelling in his legs and was pale and sweating.

One hour later, at 5:01 AM arterial blood gas test results showed that Patient 22 had an abnormally low pH (acidic) level of 7.17 (normal 7.37 - 7.47) and a high PCO2 (partial pressure of carbon dioxide) level 61.5 mmHg (normal 32 - 46 mmHg), combined together indicate impending respiratory distress (an emergency medical condition). Other laboratory blood tests showed that Patient 22 had a high potassium level 6.3 (normal 3.4 - 5.3), high levels of potassium in the blood can cause life threatening abnormal heart rhythms if not treated. Other blood test results showed that the patient had an abnormally high blood urea nitrogen 70 (normal 9 - 21) and an abnormally high Creatinine level 2.3 (normal 0.8 - 1.5) indicating kidney failure; and an elevated white blood cell count of 16.1 (normal 4.3 - 11.0), an elevated level may indicate the presence of an infection. Documentation in the medical record showed Patient 22 received intravenous (IV) antibiotics at 4:30 AM and at 6:20 AM to treat a possible infection. The medical record did not contain evidence that Patient 22 received treatment to lower his potassium level.

At 5:35 AM the ED nurse documented that Patient 22 complained of chest pain, "states it feels like an elephant sitting on his chest" and rated his pain an 8 on a scale of 1-10. Chest x-ray results showed Patient 22 had an enlarged heart (weakened heart) and excess fluid in his lungs (making it difficult to breath). Documentation in the medical record indicated Staff J, Physician Assistant Certified, (PA-C) discussed the findings with on-call physician Staff F. The medical record did not contain evidence that on-call physician Staff F came to the ED to assist in evaluating or managing Patient 22's emergency medical condition.

At 5:45 AM the ED nurse documented Patient 22 stated "help me, I need help, I'm having chest pain."

At 5:52 AM the ED nurse documented she placed a "simple face mask" on Patient 22 and continued the flow of oxygen at 6 liters. Further documentation showed that "Patient moving around still saying 'help me'." The nurse documented the patient was pale and sweating, that his oxygen saturation level dropped to a critically low level of 69% (normal 95 - 100% at rest) and that she was unable to obtain a blood pressure.

After being in the ED a little over two hours, the ED nurse documented Patient 22 became pulseless and initiated cardio-pulmonary resuscitation (CPR) at 6:15 AM per the "Code Blue Form." During the resuscitation efforts, a second arterial blood gas test was performed indicating Patient 22's pH became more acidic at 7.01 (7.17 at 5:01 AM) and his PCO2 increased to 68.8 (61.5 at 5:01 AM).

At 6:23 AM documentation on the "Code Blue Form" showed Patient 22 was intubated (a breathing tube inserted through the mouth and into the airway to assist with breathing). The patient regained a pulse but remained un-stabilized and required a continuous IV drip of Levophed (medication to raise blood pressure).

At 6:25 AM documentation showed that Staff J, PA discussed the arterial blood gas test results with on-call physician Staff F. The medical record did not contain evidence that the on-call physician came to the ED to assist in evaluating or managing Patient 22's emergency medical condition. Further documentation on the "Code Blue Form" at 6:29 AM showed that ED staff could not find that Patient 22 had a pulse and resumed CPR.

At 6:42 AM the results of Patient 22's Troponin level (proteins that are released when the heart muscle is damaged) were elevated at 0.200 nanograms/milliliter (ng/ml) (Normal less than 0.03 ng/ml), was relayed to Staff F, on-call Physician. The medical record did not contain evidence that on-call physician Staff F came to the ED to assist in evaluating or managing Patient 22's emergency medical condition.

At 6:45 AM documentation showed that Staff J, PA contacted Hospital B to initiate a transfer. Further documentation showed that from 6:40 - 6:45 AM, Patient 22's blood pressure remained critically low 80/46 - 70/50 (normal range is 120/80 - 140/90).

After being in the ED for three hours, per documentation on the "Code Blue Form" patient # 22 did not have a pulse and chest compressions were resumed at 7:04 AM. The medical record did not contain evidence that the on-call physician came to the ED to assist in evaluating or managing patient # 22's emergency medical condition.

At 7:18 AM documentation showed that Patient 22's potassium level was critically elevated at 7.5 (increased from 6.3 at 5:01 AM)

At 7:20 AM documentation showed that emergency medical services (EMS) was at the bedside for transport. Further documentation on the "Code Blue Form" showed that staff applied a temporary transcutaneous pacemaker to patient # 22's chest to stimulate the heart if the patient's pulse dropped too low.

The "Progress Notes" showed the following: "Admit: inpatient to ICU." "The patient's condition is critical." "Admit to [name of patient # 22's primary care physician]." The medical record did not contain evidence indicating why patient # 22 was not admitted to the hospital's intensive care unit (ICU) for further stabilizing treatment prior to transfer to Hospital B.

Review of the hospital's intensive care unit (ICU) census for 08/07/19 showed that there were four available beds at the time patient # 22 remained in the ED.

At 7:47 AM, documentation in the medical record indicated that patient # 22 departed the ED with EMS for transport to Hospital B.

Documentation on the "EMTALA PLUS FORM" showed that physician assistant J contacted a physician at Hospital B at 6:45 AM to arrange transfer of an "unstable" patient who required a higher level of care in an ambulance with advanced life support equipment. The medical record did not contain evidence that a physician certified the medical benefits of transfer to a hospital located approximately 80 miles away outweighed the risks. The space on the "EMTALA PLUS FORM" for the physician's countersignature was blank.

Review of a second closed medical record showed that the ambulance crew contacted the ED staff at 7:55 AM on 08/07/19 and reported that Patient 22 was back in cardiac arrest and would be returning to the ED. At 8:04 AM documentation showed that ED staff performed chest compressions and administered several medications commonly used during CPR efforts - epinephrine, sodium bicarbonate, magnesium and made adjustments to several medications already infusing intravenously. At 8:15 documentation showed Patient 22's blood pressure was 88/62 and staff were unable to obtain blood for laboratory testing. At 8:18 AM, ED staff directed the ambulance to transport Patient 22 to Hospital B while in a critical and unstable condition. The medical record did not contain evidence that Staff J, PA-C contacted the on-call physician, or that the on-call physician came to the ED to evaluate and manage the patient or certified in the medical record that the medical benefits of transfer to a hospital located over 80 miles away outweighed the risks.

Review of a third closed medical record showed that the ambulance arrived at Hospital B at approximately 9:40 AM on 08/07/19 and that cardio-pulmonary resuscitation efforts were in progress upon arrival. Documentation revealed that Patient 22's heart was not beating on its own in the ED when chest compressions were stopped and the patient was declared deceased at 9:55 AM.

During an interview on 11/05/19 at 2:06 PM, Staff I, PA-C stated that he would call a physician if "we need to admit or transfer and they would come in for a code blue." "He stated that aside from a code blue (a medical emergency in which a team of medical personnel work to revive an individual in cardiac arrest) he didn't think there is a level of acuity where he would have to call a physician to come in to examine the patient." "He stated that if a code is called the physician is expected to come in, stating he thought that no matter what the code is they are supposed to come in." Staff I stated that if he was comfortable handling the situation and the patient, he didn't have to call for assistance.

During an interview on 11/06/19 at 9:45 AM Staff K, Registered Nurse, (RN) stated that it's rare that the physicians come to the ED, and that she doesn't know for sure if a physician is required on a code. She stated that in 42 years she had never had an experience of a doctor not coming in on a code. She further stated that we admit to the ICU, if we can care for them here, we will do that.

Patient 3

Review of a document provided by the hospital titled, "Emergency Department Acute Coronary Syndrome (ACS) Orders" updated February 2018 showed: Suspect acute coronary syndrome patients with any of the following complaints: Chest pain or discomfort described as crushing, burning, pressure, tightness, heaviness, squeezing or fullness. Discomfort or pain in other areas of the body such as, abdomen, neck, jaw, back, or 1 or both arms ... Remember, women, elderly and diabetic patients may present with atypical chest pain and symptoms more frequently than men. The document showed ACS workup includes 12 Lead EKG (electrocardiogram) STAT (immediately) (Goal: within 5 minutes of arrival); 12-lead EKG interpreted by provider (Goal: within 10 minutes of arrival) ... The document further showed a goal to transfer by 30 minutes after arrival to local facility for Primary Percutaneous Coronary Intervention (PCI) (a procedure performed by inserting a catheter through the skin in the groin or arm to open narrowed arteries that supply the heart muscle with blood). "STEMI (type of heart attack) Orders for transfer to Primary PCI Facility (goal in-out of ER 30 minutes) ... Initiate plans for transport AS SOON AS STEMI is identified - don't delay for labs and X-ray results ... Labs: STAT - CBC (Complete blood count), CMP (Comprehensive Metabolic Profile), PTT (test that detects clotting defects in the blood), PT/INR (test used to help detect and diagnose a bleeding or excessive clotting disorder), Mag (Magnesium level), Troponin ...

Review of a closed medical record showed Patient 3 presented to the ED on 01/27/19 at 7:56 AM complaining of sudden onset of sweating with dizziness and upper back pain throughout the night. Documentation showed the patient "states she is concerned she is having cardiac event." "Upon arrival to ED Patient 3 states she is pain free." At 8:04 AM mid-level practitioner Staff H, PA examined Patient 3 and documented the patient presented to the ED complaining of intermittent sudden onset of upper back pain, and that she became sweaty when having pain.

At 8:14 AM an EKG was completed and reading of the patient's heart was "unconfirmed" per the machine generated tracing. Further documentation indicated the tracing was "abnormal" and showed "ST elevation" (heart attacks with ST elevation are very serious and require immediate intervention in a cardiac catheterization lab).

At 8:19 AM the ED nurse documented she gave Patient 3 Aspirin 324 mg tablet (can help dissolve a blood clot that may be causing a heart attack, an emergency medical condition).

At 9:04 AM the lab test report indicated Patient 3 had an elevated CK (Creatine Kinase) (level 239 (normal 30-135 U/L, CK levels in the blood can rise after a heart attack) and an elevated Troponin Level 5.690 (normal 0.0 - 0.050, elevated levels in the blood indicate a heart attack).

At 10:05 AM mid-level practitioner Staff H, PA documented he diagnosed the patient as having a STEMI and discussed Patient 3 with on-call physician Staff C. Further documentation showed Staff H, PA initiated transfer to the intensive care unit at Hospital B located approximately 90 miles away (approximately 1 hour and 30-minute drive) by an advanced life support equipped ambulance.

At 10:10 AM the ED nurse gave the Patient 3 a bolus of Heparin 5,000 units intravenous (IV) and initiated a Heparin drip at 10:12 AM and at 10:40 AM Patient 3 departed the ED.

The evidence in the medical record indicated there was an inappropriate long delay in care between the patient's arrival in the ED and the provision of stabilizing treatment at Hospital B. Patient 3 presented to the ED with concerning symptoms along with an abnormal and concerning EKG at 8:14 AM. The patient remained in the ED for 2 hours and 40 minutes prior to transfer to a hospital located one hour and 30 minutes away despite having an emergency medical condition (ST elevated myocardial infarction) that could deteriorate at any moment. The hospital's capabilities included an on-call physician Staff C, who did not come to the ED to evaluate Patient 3, or assist in arranging a timely transfer, or countersign the certification for transfer initiated by mid-level practitioner Staff H, PA.

During an interview on 11/05/19 at 11:44 AM, Staff H, Physician Assistant, (PA) stated that he could not say why it took so long to transfer Patient 3. Part could be waiting on the labs, part might be having to wait on an ambulance. We have that problem quite a lot. He stated that her symptoms were atypical and there was no question she had a STEMI. Staff H stated that the on-call physician probably didn't come to the ED because there wasn't anything more that the doctor could add to the patient's care. There is no reason for them to come in to see a patient and say ok transfer them out if all that stuff is already in the process.

During an interview on 11/06/19 at 11:45 AM, Staff C, Physician stated that acute myocardial infarction (heart attack) is one thing they [the physicians] don't usually get a call [about,] because they [the mid-level's] are trying to get the patient out the door. If it was my own personal patient, I would probably be notified about that because I would receive the paperwork. If it was an unassigned patient, I assume I may not know about that patient.

During an interview on 11/04/19 at 9:40 AM Staff M, Director of Inpatient and ED Services stated that they have protocols to guide the provider, like for cardiac and STEMI. She stated that the Mid-level providers are subject to protocol approved by the Med Exec committee and adopted from the Kansas Care Collaborative. They don't always collaborate with the physician if we know we cannot provide that service and they are shipped out.

Based on record review, interview, and policy review, the hospital failed to 1. Appropriately transfer patients with unstable emergency medical conditions (EMC); 2. The hospital failed to ensure an on-call or attending physician came to the hospital to evaluate and manage the care of an unstable patients with an emergency medical condition prior to transfer to another facility; and 3. The hospital failed to ensure that a physician certified, by cosigning the EMTALA Plus form, that the medical benefits outweighed the risk of transferring unstable patients with an emergency medical condition for ten patients (Patient 1, 3, 4, 5, 6, 10, 11, 18, 22, and 24) of 23 patients reviewed for appropriateness of transfer. This deficient practice has the potential to adversely affect all patients presenting to the emergency department for services and could lead to further complications or death.


Findings Include:

Patient 1

Review of a closed medical record showed Patient 1 arrived at the ED on 01/23/19 at 9:37 PM. Review of the "EMTALA Plus" form showed Patient 1 and was transferred to the receiving facility on 01/23/19 at 11:35 PM, in an unstable condition, with diagnosis of pneumonia with sepsis and acute renal failure. The reason for the transfer was documented as, "Admission." The reason for transfer of an unstable patient was not documented and left blank. The "EMTALA Plus" transfer form was not counter signed by the on-call physician. Review of the medical record, provided by the Director of Emergency Services, showed Patient 1 had diagnoses: "Pneumonia; sepsis; and, acute renal failure." The medical record showed Physician Staff B and Physician Staff C were consulted on the care of Patient 1.

During an interview on 11/05/19 at 9:59 AM, Staff M, Director of Emergency Services said, "Patient 1 was transferred to another hospital because two of our physicians [Physician B and Physician C] refused to admit her to the facility, because she had been their patient in private practice, and they had both fired her."

During an interview on 11/05/19 at 11:54 AM, Staff H, Physician Assistant (PA) said "[Patient 1] needed to be admitted, but she wasn't an unstable patient. This was the reason for the EMTALA investigation in the first place, because her physicians didn't think they had to admit her here if they had fired her from their practice." Staff H, PA, said he had talked to her physician [Staff A] who she had seen her earlier that day. She was transferred to [hospital.]"

During an interview on 11/06/19 at 9:30 AM, Staff A Medical Director said, "They talk to us about Patient 1 before. We had a med-exec [medical executive] meeting and updated our bylaws, rules, and regulation, to outline how to handle unassigned patient [like Patient 1.] According to our current bylaws, Internal Medicine should have admitted her despite her status in the clinical setting."

During an interview on 11/06/19 at 11:45 AM, Staff C, Physician said, "[Patient 1] was the patient that I had fired. As far as I knew, I thought it was okay to not accept a patient for that reason. Another Physician from the clinic would not have accepted her either. Things have changed after the EMTALA training and we now know we would have had to admit this patient. We would have been able to treat [Patient 1] here."

During an interview on 11/06/19 at 12:20 PM, Staff B, Physician said, "The PA [physician's assistant] called me after talking to another physician about admission. I did not admit Patient 1 because we only serve patients up to 18-years-old."

Patient 3

Review of a document provided by the hospital titled, "Emergency Department Acute Coronary Syndrome (ASC) Orders" updated February 2018 showed: a goal to transfer by 30 minutes after arrival to local facility for Primary Percutaneous Coronary Intervention (PCI) (a procedure performed by inserting a catheter through the skin in the groin or arm to open narrowed arteries that supply the heart muscle with blood). "STEMI (type of heart attack) Orders for transfer to Primary PCI Facility (goal in-out of ER 30 minutes) ... Initiate plans for transport AS SOON AS STEMI is identified - don't delay for labs and X-ray results ...

Review of a closed medical record showed Patient 3 presented to the ED on 01/27/19 at 7:56 AM complaining of sudden onset of sweating with dizziness and upper back pain throughout the night. Documentation showed the patient "states she is concerned she is having cardiac event." "Upon arrival to ED Patient 3 states she is pain free." At 8:04 AM mid-level practitioner Staff H, PA examined Patient 3 and documented the patient presented to the ED complaining of intermittent sudden onset of upper back pain, and that she became sweaty when having pain. Review of the "EMTALA Plus" transfer form was not counter signed by the physician.

The evidence in the medical record indicated the patient remained in the ED for 2 hours and 40 minutes prior to transfer to a hospital located one hour and 30 minutes away despite having an emergency medical condition (ST elevated myocardial infarction) that could deteriorate at any moment.

During an interview on 11/05/19 at 11:44 AM, Staff H, Physician Assistant, (PA) stated that he could not say why it took so long to transfer Patient 3. Part could be waiting on the labs, part might be having to wait on an ambulance. We have that problem quite a lot.

Patient 4

Review of a closed medical record showed Patient 4 arrived at the ED on 12/20/18 at 10:23 AM. Review of the "EMTALA Plus" form showed Patient 4 was transferred to the receiving hospital on 12/30/18 at 1:00 PM, in an unstable and stable condition [both boxes were marked and conflicting,] with diagnosis of HAP [sic] and CKD [chronic kidney disease.] The reason for transfer was documented as, "Need of dialysis." The reason for transfer of an unstable patient was documented as, "Higher level of care required ..." The "EMTALA Plus" transfer form was not counter signed by the physician. Review of Patient 4's medical record showed Patient 4 had diagnoses: kidney disease; sinus tachycardia; congestive heart failure; and, cardiac enzymes elevated. The medical record did not show documentation that an on-call physician was consulted regarding Patient 4's condition.

Patient 5

Review of a closed medical record showed Patient 5 arrived at the ED on 12/12/18 at 12:36 AM. Review of the "EMTALA Plus" form showed Patient 5 was transferred to the receiving hospital on 12/12/18 at [time not filled in,] in stable and unstable condition [both boxes were checked and conflicting,] with diagnosis of suicidal ideation, and reason for transfer, "Psychiatric." The reason for transfer of an unstable patient was not documented. The "EMTALA Plus" transfer form was not counter signed by the physician. Review of the Patient 5's medical record showed a diagnosis of depression and suicidal ideation. No documentation was found in the medical record to show involvement or consultation with an on-call physician.

Patient 6

Review a closed medical record showed Patient 6 arrived at the ED on 02/02/19 at 11:30 AM. Review of the "EMTALA Plus" form showed Patient 6 was transferred to the receiving hospital on 02/02/19 at 12:10 PM, with the condition of the patient described as "Stable," and boxes were checked for unstable condition, with diagnoses: ATV [all-terrain vehicle] accident; left hip fracture; and, free air." The reason for the transfer was [left blank]. The reason for transfer of an unstable patient was documented as, "Higher level of care is required ..." The "EMTALA Plus" form was not counter signed by an on-call physician. Review of Patient 6's medical record showed Patient 6 had a diagnosis: all-terrain vehicle accident, initial encounter; closed dislocation of hip, left, initial encounter; closed fracture of pelvis, initial encounter; and, free air. The medical record did not document the involvement or consultation with an on-call physician.

Patient 10

Review of a closed medical record showed Patient 10 arrived at the ED on 12/21/18 at 6:46 PM. Review of the "EMTALA Plus" form showed Patient 10 was transferred to the receiving hospital on 12/21/18 at 10:30 PM, with condition described as "Critical," and boxes checked for unstable condition, with a diagnosis of, "Post cardiac arrest." The reason for transfer was documented as "Higher level of care." The reason for transfer of an unstable patient was documented as "Required higher level of care..." The "EMTALA Plus" transfer form was not counter signed by the physician. Review of Patient 10's medical record showed the patient had diagnoses of altered level of consciousness and seizure. The medical record did not show documentation that an on-call physician was involved or consulted for Patient 10's care.

During an interview on 11/05/19 at 12:38 PM, Staff H, PA said, "That one falls into that weird situation [transfer of Patient 10]. I should have contacted the on-call physician at least afterword. I don't know why I didn't contact the physician. At this point I have no idea if I contacted the physician or not, or just as likely that I forgot to document contact. Those are the types of situations where you are so busy doing things that you don't contact the physician right away. I didn't feel it was necessary for the physician to come in and take over." Staff H, PA said, "That was one of those situations where the patient needs to be sent out because our facility cannot manage the patient. Sometimes we do make the call. At that point EMS [ambulance crew] probably called the helicopter while they were on the scene. I'd have to see the patient and start calling and get another hospital to accept this patient. Whether I would have called [Staff C Physician] or not would not have made a difference to this patient. I more than likely contacted [Staff C Physician] after the fact. If it's not documented (calling the on-call) I cannot say 100 percent that I called him or not." Staff H, PA said, "The on-call comes in 50-60 times a year after being informed of the situation. Probably about 1-2 times a year do I ask them to come in. When I have asked them to come, they have always come in."

Patient 11

Review of a closed medical record showed Patient 11 arrived at the ED on 01/11/19 at 7:58 AM. Review of the "EMTALA Plus" form showed Patient 11 was transferred to the receiving hospital on 01/11/19 at 9:30 AM, in unstable condition, with a diagnosis of A-fib with RVR [rapid ventricular response]. The reason for transfer was documented as, "Cardiology." The reason for transfer of an unstable patient was documented as, "Required higher level of care..." The "EMTALA Plus" transfer form was not counter signed by the physician. Review of the medical record showed Patient 11 had diagnoses of A-Fib and RVR. The medical record contained no documentation of involvement or consultation with an on-call physician.

Patient 18

Review a closed medical record showed Patient 18 arrived at the ED on 08/06/19 at 9:29 PM. Review of the "EMTALA Plus" form showed Patient 18 was transferred to the receiving hospital on 08/06/1 at 11:52 PM, in unstable condition, with diagnosis of, "Lumbar [sic] FX [fracture.]" The reason for transfer was documented as, "No neurosurgeon." The reason for transfer of an unstable patient was documented as, "Required higher level of care..."
The "EMTALA Plus" transfer form was not counter signed by the physician. Review of Patient 18's medical record showed Patient 18 had a closed fracture of the lumbar vertebra. The medical record lacked documentation of involvement or consultation with an on-call physician.

Patient 22

Review of a closed medical record showed Patient 22 arrived at the ED on 08/07/19 at 4:01 AM and discharged from the ED at 7:47 AM. Review of the "EMTALA Plus" transfer form showed Patient 22 was seen by Staff J, PA and was transferred to the receiving hospital on [date and time of transfer not filled in,] in unstable condition, with diagnoses of sepsis and code [illegible]. The reason for transfer was documented as, "No cardiologist." The reason for transfer of an unstable patient was documented as, "Higher level of care required ..." The document was signed by Staff J, PA on 08/07/19 at 6:45 AM. The "EMTALA Plus" transfer document was not counter signed by the physician. Review of the medical record show Patient 22 had diagnoses of Pneumonia and Sepsis. Staff A, Physician and Staff F, Physician were consulted for care on Patient 22.

Review of Patient 22's second closed medical record showed he arrived back at the ED on 08/07/19 at 8:02 AM and discharged at 8:18 AM. The facility failed to provide a new transfer sheet for Patient 22's second transfer from the ED to the receiving hospital. The apparent transfer occurred on 08/07/19 at 8:18 AM. The medial record lacked documentation of a new "EMTALA Plus" transfer form, and subsequently the "EMTALA Plus" transfer form was not counter signed by the physician. Review of Patient 22's medical record showed Patient 22 had diagnoses of: Cardiac arrest- on transcutaneous pacer (pace maker); sepsis; and, s/p [status post] and CABG [coronary artery bypass graft.] The medical record lacked documentation of involvement or consultation with an on-call physician.

During an interview on 11/06/19 at 4:27 PM, Staff M, Director of Emergency Services stated that the facility did not have a policy that would cover the event of someone being transferred out, and then coming back to the ED because they coded in the ambulance, and then being transferred out again. She said that because the patient had been admitted to the ED two times, the expectation would be that a second EMTALA Plus transfer form would have been filled out.

Patient 24

Review of a closed medical record showed Patient 24 arrived at the ED on 10/15/19 at 7:30 PM. Review of the "EMTALA Plus" form showed Patient 24 was transferred to the receiving hospital on 10/15/19 at 9:40 PM, in unstable condition, with diagnosis of, "MVC [motor vehicle collision] with ruptured colon." The reason for transfer was documented as, "No trauma surgeon." The reason for transfer of an unstable patient was documented as, "Higher level of care required..." The "EMTALA Plus" transfer document was not counter signed by the physician. Review of Patient 24's medical record showed Patient 24 had diagnoses Motorcycle [may be an error as triage and physician noted Patient 24 was a passenger in a vehicle] driver injury in collision with unspecified motor vehicles in traffic accident, initial encounter and traumatic large bowel perforation. The medical record lacked documentation of physician involvement or consultation of an on-call physician.

During an interview on 11/05/19 at 10:43 AM, Staff M, Director of Emergency Services said, "It used to be expected that the provider in the ER collaborate with the attending physician who was on call. The physician had 24 hours to counter sign that transfer certificate to show that they had collaborated with the mid-level. I'm not sure when they stopped having the physician sign the transfer certificate. Medical records used to send them [EMTALA Plus form] to the physicians to sign within 24 hours. The EMTALA policy that took effect on 04/11/19 specifies that stabilizing treatment will be provided, it also specifies the transfer of an unstable patient must be certified by the physician."

During an interview on 11/05/19 at 4:30 PM, Staff N, Director of Clinical Information and Information Services stated that in the past, there had been a consultant in the department that said the 2016 changes (by Kansas Board of Healing Arts,) spoke to the relationship between the physicians and the mid-level providers. The consultant had said the physician did not need to review and sign off on the mid-level records anymore. The Director of Clinical Information and Information Services said that the EMTALA forms were included in that change at the hospital. She said she had communicated with HIM (health information management) that morning and could see that the transfer forms did need to be signed. The Director of Clinical information and Information Services said that this (not having the physician counter sign the transfer forms of unstable patients) had been going on for a few months now.

During an interview on 11/06/19 at 12:46 PM, Staff M, Director of Emergency Services stated that she did not think there was a policy and procedure for obtaining the on-call physicians' certification of risks/benefits or the counter signature of the physician, other than the EMTALA, admission, discharge, and other provided emergency department policies, but there was nothing specific to the process of obtaining a written certification or signature from the physician.

During an interview on 11/06/19 at 11:45 AM, Staff C, Physician said, "I don't know if there are any requirements for the mid-level to call about transfers. I suspect that there are not because I am assuming there are transports that we don't know about. Acute myocardial infarction (heart attack) is one thing they [the physicians] don't usually get a call [about,] because they [the mid-level's] are trying to get the patient out the door. If it was my own personal patient, I would probably be notified about that because I would receive the paperwork. If it was an unassigned patient, I assume I may not know about that patient. We used to sign all of the transfer forms when someone goes through the emergency department. I have not signed off on a transfer form from the ED. We used to receive forms like that to sign, several years ago, but we do not receive them anymore. I have not signed any forms on transfers that I did not know about."

During an interview on 11/06/19 at 9:45 AM, Staff K, Registered Nurse (RN) said physician signatures were acquired through the medical records department on transfer sheets, but the mid-level called the physician to get permission to transfer the patient. She said, "That is done for every transfer. It should be done before they are transferred. They shouldn't be transferred without our medical staff knowing." Registered Nurse 1 said, "It's rare that the physicians come to the ED, but if we ask them to come, they come." Registered Nurse 1 said, regarding trauma activation, "If we know the attending physician, we will call that physician, or we will call the on-call physician. I don't know for sure if a physician is required on a code. As a nurse I don't know if a physician has been called for a transfer or not because that happens on the mid-levels side."

During an interview on 11/05/19 at 11:54 AM, Staff H, Physician Assistant said, "We talk to the physician before we transfer anybody. Ninety percent of the time we talk to the physician and the physician decides whether the patient needs to be transferred out or not. Sometimes we are transferring and then call after because the patient has to go out. Normally we talk to the doctor and they decide whether or not the patient needs to be transferred out. On the few times that we don't, it's because we know that the patient has to go out. We still contact the physician at some point. There would be trauma coming in, so we get them to our facility and stabilize them. We know that they are a multi system trauma and they will have to go out. We have to contact the receiving facility. So, we don't contact the physician right away. They have to countersign the transfer. Sometimes the physician will show up on site, it depends on the situation. Counter signature by the physician should have been put on the transfer certification, but I don't see those forms after they go out. Essentially, I talk to the physician and let them know about the patient, labs, vitals, full report, and based on those finding the physician says whether they feel the patient is stable for our facility or whether the patient needs to go out." Physician Assistant 1 said he did not document much in the medical record other then they [himself and the physician] discussed the situation.

During an interview on 11/04/19 at 11:40 AM, Staff M, Director of Emergency Services said, "It was just recently decided upon by our medical staff that they do not have to sign after a midlevel made a transfer. They used to sign off on every record post transfer. The provider calls the physician to collaborate with the physician, but not every transfer. If the patient is critical and they feel that they need assistance with that patient, they call the physician and they come in. We have protocols to guide the provider, like for cardiac, like ST elevation myocardial infarction. They don't always collaborate with the physician, if they are in need of dialysis, we know we cannot provide that, and they are shipped out."