HospitalInspections.org

Based on policy and procedure reviews, medical records reviews, hospital documentation reviews, staff and physician interviews, the hospital failed to comply with §489.24 as evidenced by the Dedicated Emergency Department (DED) physician and Obstetrical DED physician failing to complete a written physician certification for transfer and/or documenting the increased risks and benefits associated with the transfer of an individual with an Emergent Medical Condition (EMC) .

The findings include:

1. ~ cross refer to 489.24(e)(1)(2) Risks and Benefits, Tag A2409.

Based on review of current policy and procedure, Dedicated Emergency Department (DED, Emergency and Obstetrical departments) central log review, and staff interviews the hospital failed to maintain a complete central log of each individual who comes to the emergency department (ED), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged.

The findings include:

Review of the current hospital policy effective and reviewed 04/30/2012 "EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA) Policy revealed "...Hospital shall maintain the following records and retain them for a period of five (5) years:...- A central log which includes information(information on) each person who comes to the facility seeking emergency medical assistance, indicating whether he or she refused treatment, was refused treatment, or whether he or she was admitted and treated, discharged, transferred, or stabilized and transferred. This log shall state the name of such person, age, gender, the date and time of presentation, the date and time of disposition, the medical record number, nature of complaint and means of arrival and shall be maintained by the facility's emergency department and/or labor and delivery service".

Review of the DED log for the ED revealed the disposition of patients presenting to the ED requesting services was not documented. Review of the log revealed the following months: May 2014 had 42 patients without documentation of disposition, June 2014 had 38 patients without documentation of disposition, July, 2014 had 43 patients without documentation of disposition, August, 2014 had 55 patients without documentation of disposition, September, 2014 had 50 patients without documentation of disposition and October, 2014 had 97 patients without documentation of disposition.

Interview with DED administrative staff on 10/29/2014 at 1445 revealed the DED staff did not review the DED log for completeness.

A request for the Obstetrical Log for patients presenting to the OB (Obstetrical) Department requesting emergency services was made on 10/27/2014 at 1430. A second request was made for the OB log on 10/28/2014 at 0930. The staff presented a log on 10/28/2014 at 1545. Review of the log revealed no documentation of a patient's disposition.

Interview with OB Administrative and Accreditation staff on 10/28/2014 at 1545 revealed the OB log did contain the disposition of the patients. The interview revealed the staff would have to create a log to have a disposition documented.

Based on policy and procedure reviews, closed medical record reviews, staff and physician interviews the hospital's Dedicated Emergency Department (DED) failed to ensure an appropriate transfer by failing to: complete a written physician certification for transfer and/or document the medical benefits reasonably expected at the time of transfer outweighed the increased risks associated with the transfer to individuals in 6 of 11 (3 of 7 ED and 3 of 4 Obstetrical) DED patients having an Emergency Medical Condition (EMC) that were transferred to another hospital ( DED Patients #27, #24, #23, Obstetrical patients #19, #20, #29) .

The Findings include:

Review of the current hospital policy effective and reviewed 04/30/2012 "EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA) Policy revealed "...Hospital shall not transfer him or her to another facility unless: - the patient (or a legally responsible person acting on the patient's behalf), after being informed of the XXX (name of hospital system) Hospital's obligation and of the risk of transfer, request transfer to another facility in writing which also indicates the reason for the request and that the person making the request is aware of the risks and benefits of the transfer; or - physician (or other qualified person in consultation with a physician when a physician is not physically present) has signed a certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of medical treatment at another medical facility outweigh the increased risks to the patient, and in the case of labor to the unborn child, from effecting the transfer. However, if a physician is not physically present in the emergency department and a qualified medical person has signed a certification after consultation with a physician , the physician shall subsequently countersign such certification. The certification must contain a summary of the risks and benefits upon which it is based...This information will be documented on the XXX form "Interfacility Transfer of Patient/EMTALA"

1. Medical record review of Patient # 27 revealed a 22 year old presenting to Hospital A's (transferring hospital) DED on 08/19/2014 at 1510 with a chief complaint of abdominal pain. Record review at 1530 the patient complained of nausea and the abdominal pain was radiating to her shoulder. The physician started the Medical Screening Exam (MSE) at 1550. Review of the MSE revealed the patient had a history of pelvic and the abdomen had "tenderness". Further review of the MSE revealed "Has pain in the lower abdomen that is reproducible with palpation. The pain is severe and becomes much worse with movement as well. She is afebrile. The U/S (ultrasound) from last night showed a very large pelvic mass with some internal debris and a solid component to it". Record review revealed a Gynecology consultation was requested. Review of the gynecology consultation report at 1815 revealed "acute onset of abdominal pain in the setting of known large pelvic mass...Abdomen: normal bowel sounds, mildly distended, tympanic to percussion (painful), abdomen is diffusely tender, worse with rebound, + (positive) voluntary guarding, large midline mass palpable a few centimeters below the umbilicus, midline vertical and Pfannenstiel incisions well healed...A large pelvic mass is present posterolateral to the uterus on the left. This large cystic mass has some internal debris and solid component. The mass is too large to image within a single field of view. Estimated size is approximately 18.6 x 16 x 12 cm (centimeters)...Impression: Large complex cystic pelvic mass. Ovarian neoplasm is certainly not excluded...abdominal exam is concerning for possible ruptured/bleeding cyst. She is currently hemodynamically stable, however her exam findings of rebound tenderness warrant an overnight admission for close observation. In the event that she needs to be taken to the operating room overnight or tomorrow." Record review revealed the patient was transferred to Hospital B at 2044. Record review did not reveal any documentation of the written physician certification for transfer.
Medical record review from hospital B (receiving hospital) revealed the patient was received at Hospital B and was admitted as an inpatient for work up for genealogical surgery.

Interview on 10/29/2014 at 1355 with DED physician #1 revealed when a patient is transferred with an EMC/"EMTALA" the nurse prints the EMTALA forms. The physician signs the forms along with the patient and/or the patient's representative. The interview revealed the nurse will not allow the patient to leave the DED until the physician signs the written physician certification to transfer. The interview revealed there are choices for the risk and benefits in the electronic medical record. The interview revealed the physician chooses from the preselected menu. The interview revealed the choices for risk are "discomfort, worsening condition, time delay and loss of IV". The interview revealed there is a line designated "other" in which the physician is to document specific risks.

Interview on 10/29/2014 with Administrative hospital staff at 1415 revealed the hospital process for obtaining the physician certification for transfer is the staff will print the form off for the physician and patient to sign. The printed documents are scanned into the system for the electronic medical record. The interview revealed the medical record for DED patients is mostly electronic and the record will eventually be all electronic but the hospital was not completing the EMTALA paperwork electronically yet. The interview revealed there was no documentation available for written physician certification for transfer for Patient #27. The interview revealed the document should have been scanned in but the staff was not able to locate the information.

2. Medical record review of Patient # 24 revealed a 12 year old presenting to Hospital A's (transferring hospital) DED on 07/06/2014 at 0929 with a chief complaint vomiting, hyperglycemia, and Juvenile diabetes. Record review revealed at 1010 nursing documentation "Pt (patient) having nausea/vomiting last night, blood sugars have been elevated, "High" in triage as per father urine has elevated ketones". Review of the MSE revealed the patient was administered an insulin drip and "clinically dka (diabetic ketoacidosis) will admin(administer) ns (normal saline) bolus x 2...". Record review revealed at 1109 the the patient's glucose was greater than 600 and the patient was going to be transferred to Hospital B (receiving hospital) due to need for Pediatric Intensive Care (Specialty care not provided by Hospital A). Record review revealed the patient left the DED at 1253 via Emergency Medical Services for transfer to Hospital B. Record review did not reveal any documentation of the written physician certification for transfer.

Medical record from Hospital B revealed the patient was received and was admitted to the Pediatric Intensive Care unit.

Interview on 10/29/2014 at 1355 with DED physician #1 revealed when a patient is transferred with an EMC/"EMTALA" the nurse prints the EMTALA forms. The physician signs the forms along with the patient and/or the patient's representative. The interview revealed the nurse will not allow the patient to leave the DED until the physician signs the written physician certification to transfer. The interview revealed there are choices for the risk and benefits in the electronic medical record. The interview revealed the physician chooses from the preselected menu. The interview revealed the choices for risk are "discomfort, worsening condition, time delay and loss of IV". The interview revealed there is a line designated "other" in which the physician is to document specific risks.

Interview on 10/29/2014 with Administrative hospital staff at 1415 revealed the hospital process for obtaining the physician certification for transfer is the staff will print the form off for the physician and patient to sign. The printed documents are scanned into the system for the electronic medical record. The interview revealed the medical record for DED patients is mostly electronic and the record will eventually be all electronic but the hospital was not completing the EMTALA paperwork electronically yet. The interview revealed there was no documentation available for written physician certification for transfer for patient #24. The interview revealed the document should have been scanned in but the staff was not able to locate the information.

3. Medical record of Patient #23 revealed a 38 year old presenting to Hospital A's (transferring hospital) DED on 07/23/2014 at 0126 with a chief complaint of chest pain.. Record review revealed at 0131 nursing documentation "Chest pain-mid sternal area, pt (patient) sts (states) sometimes can feel it in the back-started around 12:30 pm today after eating lunch, started to choke-felt a pc (piece) of food that was stuck, threw up and all day was feeling what felt like undigested food stuck. Since then, went to UC (urgent Care) and was given GI cocktail but pt refused. Pt took Mylanta at home. Pt sts she now feels like she is having an asthma attack". Record review revealed vital signs documented at 0134 heart rate 101 respirations 20, Blood pressure 131/84, pulse oxygenation on room air 98%, "Pain assessment : 0-10 ("when I don't breathe, its like a 1, but when I breathe it's a 3 or a 4 and sometimes a 7"). Record review revealed the patient indicated "pain was worse when drinking ginger ale". Review of the MSE revealed results were positive for chest pain and positive for shortness of breathe and cough". Medical record review revealed a CT Scan was completed at 0341 with results "Small amount of air is present between the posterior wall of the esophagus and the descending thoracic aorta just below...This finding consistent with extraluminal gas/pneumomediastinum. When give clinical history, findings are most concerning for esophageal injury/Boerhaave's syndrome (esophageal rupture). Record review revealed the patient was transferred at 0609 to Hospital B for specialized thoracic surgery. Record review revealed documentation of an "Interfacility transfer of an unstable patient (EMTALA) form". Review of the documentation revealed no documentation of the physician signing the form. Further record review did not reveal documentation of physician written certification for transfer.

Medical record review from Hospital B revealed the pateint was received and admitted fopossible cardiothoracic surgery.

Interview on 10/29/2014 at 1355 with DED physician #1 revealed when a patient is transferred with an EMC/"EMTALA" the nurse prints the EMTALA forms. The physician signs the forms along with the patient and/or the patient's representative. The interview revealed the nurse will not allow the patient to leave the DED until the physician signs the written physician certification to transfer. The interview revealed there are choices for the risk and benefits in the electronic medical record. The interview revealed the physician chooses from the preselected menu. The interview revealed the choices for risk are "discomfort, worsening condition, time delay and loss of IV". The interview revealed there is a line designated "other" in which the physician is to document specific risks.

Interview on 10/29/2014 with Administrative hospital staff at 1415 revealed the hospital process for obtaining the physician certification for transfer is the staff will print the form off for the physician and patient to sign. The printed documents are scanned into the system for the electronic medical record. The interview revealed the medical record for DED patients is mostly electronic and the record will eventually be all electronic but the hospital was not completing the EMTALA paperwork electronically yet. The interview revealed there was no documentation available for written physician certification for transfer for patient #23. The interview revealed the EMTALA transfer documentation was completed and id not have written physician certification The interview revealed the document had been scanned in but, was not completed.

4. Medical record review of Patient #19 revealed a 33 year old female that presented to Hospital A (transferring hospital) Labor and Delivery unit on 10/07/2014 at 0753 with a chief complaint of increasing blood pressure. Record review revealed the patient was triaged at 0805 and the MSE was conducted at 0825. Review of the "Labor & Delivery Admission History and Physical" dated 10/07/2014 at 1058 revealed the patient was a Gravida 2, Para 0 (second pregnancy) at 31 weeks and 2 days gestation. Record review revealed documentation at 0815 patient's blood pressure was 151/88, at 0825 161/90, at 0900 155/100, at 1030 142/84, at 1100 153/90, at 1130 146/96, and at 1200 144/88. Review of lab results at 0918 revealed glucose 168 (normal 70-99 mg/dL). Review of lab results at 0921 revealed total protein urine was 21 (normal < 12 mg/dL). Review of the physician notes at 1058 revealed the patient had a new onset pre-eclampsia with Insulin-Dependent Diabetes. Review of the physician notes regarding the plan for the patient revealed transferring the patient to another local Hospital B (receiving hospital). Review of the form (Interfacility Transfer of a Patient Covered by EMTALA) dated 10/07/2014 at 1115 revealed documentation of risk was "transport." Record review revealed no documentation of risks of transfer to patient relative to patient's condition. Further record revealed no further documentation of risk. Review of Hospital B's medical record revealed the patient was admitted for severe pre-eclampsia.
Interview with the Labor and Delivery Clinical Nurse IV on 10/29/2014 at 1500 revealed the risks associated with transfer are to be discussed with the patient and documented on the "Interfacility Transfer of a Patient Covered by EMTALA" form. Interview revealed there was no physician documentation of the risk of the transfer for Patient #19.
5. Medical record review of Patient #20 revealed a 19 year old female presenting to the DED on 07/25/2014 at 2058 with a chief complaint of vaginal discharge and OB evaluation for less than 20 weeks of pregnancy. Record review revealed the patient was triage at 2108 and the MSE was conducted at 2122. Review of the Medical Screening Exam (MSE) revealed the patient did not know that she was pregnant until the morning of 07/25/2014 when she had vaginal discharge and took a home pregnancy test. Record review revealed the patient also had some vaginal cramping after pelvic exam. Review of the Ultrasound result dated 07/25/2014 at 2314 revealed the patient was approximately 34 weeks 3 days gestational age, +/- 21 days of pregnancy. Record review revealed the patient was diagnosed with vaginal discharge in pregnancy, unspecified trimester, pregnancy complicated by obesity, third trimester with no prenatal care. Record review revealed at 2346 the patient was transferred to Labor and Delivery for further work-up and monitoring. Record review revealed documentation by the physician that the patient's cervix was approximately 3 cm dilated, effacement 70 %, and station -1, with breech presentation. Record review revealed the patient was diagnosed with preterm premature rupture of membranes (PPROM). Record review revealed, "U/S (ultrasound) today places the patient around 34 weeks, although given the margin of error with third trimester ultrasounds, and lack of prenatal care, she could be 31 weeks or perhaps slightly less. Given uncertainty of dating, and comfort of Hospital A (transferring hospital) NICU to care for infants < 32 weeks, will plan on transfer to Hospital B (receiving hospital) for further management." Review of the form (Interfacility Transfer of a Patient Covered by EMTALA) dated 07/26/2014 at 0154 revealed documentation of risk was blank. Further record revealed no documentation of risk. Record review revealed the patient was transferred by Emergency Medical Services at 0245 to Hospital B (receiving hospital). Review of Hospital B's medical record revealed the patient was admitted and delivered the preterm baby.
Interview with the Labor and Delivery Clinical Nurse IV on 10/29/2014 at 1500 revealed the risks associated with transfer are to be discussed with the patient and documented on the Interfacility Transfer of a Patient Covered by EMTALA form. Interview revealed there was no physician documentation of the risk of the transfer for Patient #20.
6. Medical record review of Patient #29 revealed a 36 year old female that presented to Hospital A (transferring hospital) Labor and Delivery unit on 09/18/2014 at 2208 with a chief complaint of vaginal bleeding. Record review revealed the patient was triage at 2210. Record review revealed dated 09/18/2014 at 2230, at 2300, at 2330, and dated 09/19/2014 at 0000 documentation of the patient's uterine contraction frequency of 2-3 minutes with duration of 50-70 seconds. Record review revealed the MSE was done at 2220. Review of the physician subjective notes revealed the patient was a Gravida 1, Para 0 (one pregnancy) at 29 weeks and 1 day gestation by ultrasound with an EDC (due date) of 12/03/2014. Record review revealed the patient was presented "to L&D today secondary to two episodes of bleeding and passage of mucus." Review of the physician objective notes revealed the effacement of the cervix was 50% at -3 station. Review of the physician's assessment and plan revealed "..third trimester bleeding, unclear etiology, partial abruption vs PTL (preterm labor), case discussed with [Dr's name] at a local hospital (Hospital B-receiving hospital), she has agreed to accept this patient in transfer. Will proceed with IVF (intravenous fluid) and B-methasone (use of beta-Methasone in management of PPROM). The patient's questions were answered. She understands the rational for transfer to the local hospital (Hospital B-receiving hospital), for tertiary nursing and MFM (maternal-fetal medicine) care. Pt (patient) is in agreement to transfer." Review of the form (Interfacility Transfer of a Patient Covered by EMTALA) dated 09/18/2014 at 2327 revealed documentation of risk was "none," documentation of benefits was "as above." Record review revealed no documentation of risk and benefit of transfer to patient relative to patient condition. Further record revealed no documentation of risk and benefit. Review of Hospital B's medical record revealed the patient was admitted for preterm contractions with vaginal bleeding.
Interview with the Labor and Delivery Clinical Nurse IV on 10/29/2014 at 1500 revealed the risks associated with transfer are to be discussed with the patient and documented on the Interfacility Transfer of a Patient Covered by EMTALA form. Interview revealed there was no physician documentation of the risk of the transfer for Patient #29.

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