HospitalInspections.org

Based on review of medical records, staff interviews, Medical Staff Rules and Regulations, review policies and procedures review, review of facility Quality and Patient safety Committee, review of video surveillance, credential file and personal files, it was determined that the facility failed to provide an appropriate medical screening examination to an individual who presented to the hospital's emergency department (property) requesting an examination or treatment of a medical condition for 1 (Patient #21) sampled patient.

Refer to findings in Tag 2406.

Based on review of medical records, staff interviews, Medical Staff Rules and Regulations, review policies and procedures review, review of facility Quality and Patient safety Committee, review of video surveillance, credential file, and personal files review, it was determined the facility failed to an appropriate medical screening examination to an individual who presented to the hospital's emergency department (property) requesting an examination or treatment of a medical condition for 1 (#21) sampled patients.

The findings were:


1. Surveillance Video
A review of the facility's 12/19/18 surveillance video on 1/24/19 at 1:30 pm in the Chief of Security's office revealed the following:
2:50 p.m. - a white transport van parked near the Emergency Rooms (ER) entrance. Transporter AA walked into ER heading in direction of the bathroom.
2:54 p.m.- Transporter AA walking towards ER entrance from direction of the bathroom. Transporter AA interacted with occupant in a white car. (No audio available)
2:55 p.m.- Transporter AA re-enters ER, stands in one place and appears to be looking around moving his head from side to side. Transporter AA exits the ER and interacts again with the occupant in the white car.
2:56 p.m. Transport AA enters white transport van and begins driving off. Occupant in white car also begins to drive off.

2. Grievance and Complaint Log
Review of the facility's Grievance and Complaint log from 08/2018 - 1/24/19, revealed that Patient #21 had called the facility's complaint department on 12/19/18 reporting that she had sustained an injured ankle on her job and had driven herself to the facility's Emergency Room. (ER). The log further revealed that Patient #21 had asked a facility employee (Transporter AA) for a wheelchair. The facility employee (Transporter AA) had entered the ER to search for a wheelchair but returned and informed Patient #21 that there were no wheelchairs.
Patient #21 then drove to another facility. The Grievance and Complaint log also revealed that an Issue ID identifier was assigned to the complaint and an email sent to the facility's leadership including the Chief Nursing Officer.

3. Staff Interviews
An attempt on 1/24/19 at 1:45 pm, to contact Transporter AA via a listed telephone number located in his personnel record failed.

a. During an interview with the Director of Accreditation (DA) in the Medical Staff President's office on 1/23/19 at 1:30 p.m., The DA stated the Patient #21 arrived at the Emergency Department entrance, and there was also one of the facility's transport staff member (Transporter AA) waiting in his van. The DA stated transport staff normally would not be present at the ED entrance. The DA further stated, that the transport team member Transporter AA, was an employee of the facility and not a contractor. The DA stated that Patient #21 needed a wheelchair and that AA went into the Emergency Department to search for a wheelchair but was not able to find a wheelchair for Patient #21. The DA stated Patient #21 left the campus, and that Transporter AA did not inform any Emergency Department staff of the incident. The DA stated Transporter AA retired in December 2018 and is no longer an employee at the facility.

b. An interview with the Chief Medical Officer (CMO) on 1/24/2019 at 9:46 a.m., in the Medical Staff President conference room revealed that the CMO has been employed at the facility since 1989 and has been in the role of CMO since 2004. He stated that he first became aware of the circumstances involving Patient #21 from the compliance personnel after Patient #21 called and logged a complaint. The CMO then notified the facility ' s Risk Manager/Attorney who the CMO asked to assist the compliance department in its investigation. The CMO further stated per his understanding, Patient #21 made initial contact with a non-emergency transport driver in the facility ' s parking lot and requested a wheelchair. Per the CMO, it was not clear if Patient #21 was requesting a wheelchair for herself or another person and that the facility was not able to confirm if Patient #21 was treated at another medical facility. The CMO stated that video surveillance was utilized in identifying the involved facility employee. The CMO stated that any occurrences involving Emergency Medical Treatment and Labor Act (EMTALA) are typically tracked, including all Left Without Been Seen and Against Medical Advice patients from the Emergency Department (ED). The CMO added that regarding physicians with approved privileges for employment at the facility, a Memorandum of Understanding (MAU) is signed after viewing an on-line EMTALA power point and that EMTALA training is included in all new hire personnel on-boarding period. The CMO stated that it is the facility ' s intention that everyone in the facility ' s system, has EMTALA awareness.

c. During an interview with the Associate Director in Training of the ED/Director of Transport EE on 1/24/19 at 10:10 a.m., stated he worked on the day of the incident, but he was not present during the time of the location of the incident and was first informed of the incident by his superior. Associate Director in Training of the ED/Director of Transport EE further stated, wheelchairs were normally located at the front entrance and at different alcoves/storage areas in the ED. During a second interview with Associate Director in Training of the ED/Director of Transport EE at 11:45 a.m., he stated there were approximately 70 wheelchairs for the entire hospital. Associate Director in Training of the ED/Director of Transport EE stated he met Transporter AA for the first time at the Transporter AA's retirement gathering at the hospital. Associate Director in Training of the ED/Director of Transport EE stated he spoke with the Transport Team Manager to inquire if staff had EMTALA training. Associate Director in Training of the ED/Director of Transport EE stated, based on his assessment the majority of the Transport team needed an EMTALA refresher training. Associate Director in Training of the ED/Director of Transport EE stated training for the Transport team took place after the incident during the month of December 2018.

d. During an interview with RN FF in the Emergency Department (ED) on 1/24/19 at 10:10 a.m., RN FF stated she did not work the day of the incident on 12/19/18. RN FF further stated, she was approached and responded to patient needs over her eight years as an ED nurse at the facility by non-clinical personnel of patients, persons whom needed medical care. RN FF was able to describe the hospital's EMTALA policy and she stated her last EMTALA training was within the last calendar year.

e. During an interview with Security Officer GG at the front entrance of the Emergency Department (ED) on 1/24/19 at 10:50 a.m., Security Officer GG stated he has assisted persons who presented to the Emergency Department (ED) outside and inside entrance of the ED. Security Officer GG further stated, for those who needed medical assistance he would notify a nurse to facilitate care. Security GG was able to satisfactory describe EMTALA and his role with the requirement and stated that he has received EMTALA training.

f. An interview with Transporter BB on 1/24/2019 at 11:50 a.m., in the Medical Staff President conference room revealed that he has been employed at the facility for four and a half years. He described the Emergency Medical Treatment and labor Act (EMTALA) as not refusing anyone whose seeking treatment or to a pregnant woman who's in active labor. Transporter BB states that in the event a person approaches him for assistance anywhere on the facility's property, security notification is done. Transporter BB added that he does not drive the transport vehicle but at times, assist when two persons are needed to assist a patient. Transporter BB stated that wheelchairs are stored in the department and utilized once an assignment is given. Transporter BB added that the Transport department currently houses 12-15 wheelchairs with a recent receipt of 10-12 new wheelchairs.

g. During an interview with Security Officer HH in the Medical Staff President's office on 1/24/19 at 11:55 a.m., she stated that she could not remember if she worked on the day of the incident on 12/19/18. Security officer HH further stated that she worked different areas of the hospital but was not at the front entrance of the Emergency Department (ED) often. Security Officer HH stated when she is approached by people who need medical help, she assists where she is capable, or she notifies clinical staff members to facilitate care. Security Officer HH satisfactorily described EMTALA and her role with the requirement and stated she last received EMTALA training October 2018.

h. An interview with Housekeeper KK on 1/24/2019 at 1:37 pm., in the Medical Staff President conference room revealed that she has been employed at the facility for three years. Housekeeper KK described viewing a video about EMTALA during her facility orientation. She stated that her understanding of the Emergency Medical Treatment and labor Act (EMTALA), is to provide assistance to the patient when they are in need and that situations frequently arises, where she renders assistance to anyone who needs it. Housekeeper KK described a recent occurrence, where a passenger upon disembarking from the bus, at the bus stop in front of the facility, immediately requested her assistance. Housekeeper KK then notified security who brought a wheelchair and took the passenger to the emergency department.

i. During a phone interview with Security Officer JJ on 1/24/18 at 1:45 p.m., he stated he worked on the day of the incident 12/19/18. Security Officer JJ stated he was at the front entrance of the Emergency Department (ED) speaking with another staff member (unnamed). Security Officer JJ further stated on the day and time of the incident, he observed Transporter AA entering the ED front entrance searching for "something" at the front entrance and behind the security desk. Security Officer JJ stated AA did not say one word to him and the other staff member, and that Transporter AA did not stay long and proceeded to go out of the ED front entrance. Security Officer JJ satisfactorily described EMTALA and his role regarding the requirement.

4. Medical Staff Rules and Regulations
"Rules and Regulations", dated 12/11/18 revealed that the purpose of Emergency admissions was to identify those patients most in need of emergency care, patients who present to the Medical Center seeking emergency care may be triaged by an Emergency Department Nurse before being examined by a physician or other Practitioner authorized to perform a screening examination. Further policy review revealed that any individual who comes to the Medical Center Emergency department requesting examination or treatment shall be provided with an appropriate medical screening examination (MSE). The purpose of the MSE is to determine if the individual is experiencing an emergency condition.

5. Review of facility Policy and Procedures included but were not limited to the following:

a. "EMTALA-Signage Policy", dated 2/18 revealed documentation that all of the facility's emergency departments and any other place likely noticed by all individuals entering the emergency department and those individuals waiting for examination and treatment in areas of the hospital other than the traditional emergency department such as the entrance area, admitting areas, waiting rooms, and treatment areas located on hospital property must post conspicuously, appropriate signage notifying individuals of their right to an MSE (medical screening examination) and stabilization or treatment for an EMC (emergency medical condition) and required services for women in labor as specified under EMTALA as well as information indicating whether or not the hospital participates in the Medicaid program. The policy further revealed documentation, all hospitals must post signage that, at a minimum, meets the following requirements: - signage must be conspicuously posted in any place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than the traditional emergency department (e.g., entrance, admitting area, waiting room, labor and delivery, and other treatment areas located on hospital property): - signage must be readable from anywhere in the area - wording on signage must be clear and in simple terms in a language(s) that is (are) understandable by the population the hospital serves. The contents of the signage must: - indicate whether or not the hospital participates in a Medicaid program approved under a State plan under Title XIX; - specify the rights of individuals with EMCs to receive an MSE and necessary stabilization and treatment for any EMC regardless of the ability to pay; and - specify the rights of women in labor who come to the emergency department for health care services.
The signage content must include the following language:
IT ' S THE LAW!
If you have a medical emergency or are in labor, even if you cannot pay or do not have medical insurance or you are not entitled to Medicare or Medicaid, you have the right to receive, within the capabilities of this hospital ' s staff and facilities: An appropriate medical screening examination; necessary stabilizing treatment (including treatment for an unborn child); and if necessary, an appropriate transfer to another facility. This hospital (does/does not) participate in the Medicaid program.
b. " Triage " dated 1/2016 revealed that it's the facility's emergency department policy to categorize individuals seeking treatments into five priority levels to determine the appropriate order for care to be provided. Continued policy review revealed definition of terms as follows: Emergency severity index (ESI) - a five level triage system that facilitates the prioritization of patients based on the urgency of the patient's condition and how many resources each patient will utilize.
Triage- a process where a rapid, systematic collection of data relevant to each patient's chief complaint, age, cognitive level and social situation is conducted to obtain sufficient information to determine patient acuity and any immediate physical or psychological need. The process includes sorting and prioritizing patients for the most efficient and appropriate treatment area.
Priority level 1 (Critical)- The patient requires immediate life-saving interventions.
Priority level 2 (Emergent)- The patient is at high risk for rapid deterioration or presents with symptoms suggestive of a condition requiring time-sensitive evaluation and treatment.
Priority level 3 (Urgent)- The patient does not fit the criteria for level 1 or 2. Patient is predicted to require two or more resources based on the ESI resource list. The patient may require an in-depth evaluation but are felt to be stable in the short term.
Priority level 4 (Non-urgent)- The patient does not fit the criteria for level 1, 2, or 3. This patient will require only one resource based on the ESI resource list and are considered stable.
Priority level 5 (Minor)- The patient does not fit the criteria for level 1, 2, 3, or 4 and will require no resources based on the ESI resource list. A Registered Nurse who has maintained annual training and updates will perform the initial triage. The registered nurse that is assigned to triage location is required to have a minimum of one year of emergency nursing experience.

c. " EMTALA - Medical Screening Examination and Stabilization ", dated 2/2018 revealed its purpose is to reflect guidance under the Emergency Medical Treatment and Labor Act (EMTALA). An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and 1) the individual or a representative acting on the individual ' s behalf requests an examination or treatment for a medical condition or 2) a prudent layperson observer would conclude from the individual ' s appearance or behavior that the individual needs an examination or treatment of a medical condition. Continued policy review revealed that such obligation is further extended to those individuals presenting elsewhere on hospital property requesting examination or treatment for an emergency medical condition (EMC). Further, if a prudent layperson observer would believe that the individual is experiencing an EMC, then an appropriate MSE, within the capabilities of the hospital ' s DED (including ancillary services routinely available and the availability of on-call physicians). The MSE must be completed by an individual (i) qualified to perform such examination to determine whether an EMC exists, or (ii) with respect to a pregnant woman having contractions, whether the woman is in labor and whether the treatment requested is explicitly for an EMC. If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer as defined by and required by EMTALA. Stabilization treatment shall be applied in a non-discriminatory manner (e.g., no different level of care because of age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identification or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state or local law.

d. "EMTALA-Central Log Policy", dated 2/18 revealed documentation that the hospital would maintain a Central Log containing information on each individual who comes on the hospital campus requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination would be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged. The policy further revealed documentation, the Central Log include patient logs from the traditional ED (Emergency Department) and either by direct, or indirect reference, patient logs from any other areas of the hospital where an individual may present for emergency services or receive a medical screening examination, such as Labor and Delivery. The policy revealed documentation that the Central Log must contain at a minimum, the name of the individual and whether the individual: - refused treatment, -was refused treatment, -was transferred, -was admitted and treated, -was stabilized and transferred, -was discharged, or -expired. The policy revealed documentation duplicate accounts created for the same patient who visited the hospital on more than one occasion would be consolidated so that only one medical record number per patient existed; and the Central Log would be retained for a minimum of five years from the date of disposition of the individual.

e. "EMTALA -Provision of On-Call Coverage Policy", dated 2/18 revealed documentation that the facility must maintain a list of physicians on its medical staff who have privileges at the hospital or, if it participated in a community call plan, a list of all physicians who participate in such plan. The policy further revealed, physicians on the list must be available after the initial examination to provide treatment necessary to stabilize individuals with EMCs who are receiving services in accordance with the resources available to the hospital. The hospital ensured privileged physicians were aware of their legal obligations as reflected in the policy and the Medical Staff Bylaws and would take all necessary steps to ensure that physicians perform their obligations as set forth herein and in each document. The policy revealed documentation that the facility ' s governing board required that the medical staff be responsible for developing an on-call rotation schedule that included the name and direct telephone number or direct pager of each physician who required to fulfill on-call duties. Practice group names and general office numbers were not acceptable for contacting the on-call physician. Individual physician names with accurate contact information, including the direct telephone number or direct pager where the physician can be reached, are to be put on the on-call list. The hospital must be able to contact the on-call physician with the number provided on the list. If the on-call physician decides to list an answering service number as the preferred method of contact, his/her mobile phone number must be provided to the hospital as a backup number to reach the on-call physician. The backup number will be used by hospital and Transfer Center personnel when the On-Call Physician does not respond to calls in a timely manner. Each physician was responsible for updating his or her contact information as necessary and each hospital shall provide a copy of the daily on-call schedule to the Transfer Center. The on-call schedule may be by specialty or sub-specialty (e.g., general surgery, orthopedic surgery, hand surgery, plastic surgery), as determined by the hospital and implemented by the relevant department chairpersons. The Medical Executive Committee ("MEC ") shall review the on-call schedule and make recommendations to the CEO when formal changes are to be made or when legal and/or operational issues arise. The policy further revealed documentation that the hospital would keep local Emergency Medical Services advised of the times during which certain specialties are unavailable. The policy revealed documentation that the hospital must keep a record of all physicians on-call and on-call schedules for at least five years. On more than one occasion would be consolidated so that only one medical record number per patient existed; and the Central Log would be retained for a minimum of five years from the date of disposition of the individual.

f. "EMTALA-Transfer Policy", dated 2/18 revealed documentation that any transfer of an individual with an EMC must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual ' s behalf or by a physician order with the appropriate physician certification as required under EMTALA. EMTALA obligations regarding the appropriate transfer of an individual determined to have an EMC apply to any emergency department ("ED") or dedicated emergency department ("DED ") of a hospital whether located on or off the hospital campus and all other departments of the hospital located on hospital property. The policy further revealed documentation, that a hospital with specialized capabilities or facilities (including, but not limited to burn units, shock-trauma units, neonatal intensive care units, dedicated behavioral health units, or regional referral centers in rural areas) shall accept from a transferring hospital an appropriate transfer of an individual with an EMC who requires specialized capabilities if the receiving hospital has the capacity to treat the individual. The transferring hospital must be within the boundaries of the United States. The transfer of an individual shall not consider age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identity or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state or local law, except to the extent that pre-existing medical condition or physical or mental handicap is significant to the provision of appropriate medical care to the individual. The policy revealed documentation that the CEO must designate in writing an administrative designee by title responsible for accepting transfers in conjunction with a receiving physician. The CEO administrative designee, in conjunction with the receiving physician, e.g., ED physician, has authority to accept the transfer if the hospital has the capability and capacity to treat the individual. The policy further revealed processes in place for patients that who have not been stabilized, patients not stabilized that require a higher level of care, patients moved to diagnostic facilities, patients moved to off campus hospital based affiliates to non-affiliated hospital, pre-existing transfer agreements, transfers for high risk deliveries, diversion/exceeded capacity, lateral transfers, women in labor, and patients placed on observation status.

6. Quality and Patient Safety Meeting
A review of the facility's Quality and Patient Safety Committee Agenda dated 11/6/18 revealed documentation the facility discussed EMTALA Compliance Quality, a PowerPoint of EMTALA requirements.

7. Credentialing File
A review of one (1) credential file (Medical Director of Emergency Room LL) revealed current state licensure, delineation of privileges and evidence of EMTALA training within the past year.

8. Personnel Files
A review of five (5) personnel files (Transporter AA, Transporter BB, Nurse Manager of Emergency Room FF, Security Officer JJ and Housekeeper KK) revealed current state licensure (where applicable), facility required orientation, competency testing and EMTALA training.

The facility failed to ensure that their policies and procedures and Medical Staff Bylaws were followed as evidenced by failing to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed for Patient #21, who presented to the hospital's emergency department (property) requesting an examination and/or treatment for an ankle injury on 12/19/2018.