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Based on staff interviews and review of medical records, policies/procedures and Medical Staff Bylaws, the facility failed to comply with the Medicare provider agreement as defined in 489.20 and 489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

Findings:

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag A2402 Posting of Signs
The facility failed to post signage visual to all individuals entering the emergency department that specifies the rights of individuals with respect to examination and treatment of emergency medical conditions, as well as whether the facility participates in the Medicaid program under a State approved plan.

Tag A2404 On-call Physicians
The facility failed to ensure that the required policies and procedures were in place that addressed specialty physician on-call availability/response expectations. The facility also did not have a policy that addressed circumstances in which the on-call specialist was unable to respond due to circumstances beyond his/her control.

Tag A2406 Medical Screening Examination
The facility failed to provide an initial MSE (Medical Screening Exam) for one (sample #18) of 20 medical records reviewed. Specifically, the MSE was not performed on the pediatric patient who presented for a chief complaint of a head injury.

Tag A2407 Stabilizing Treatment
The facility failed to ensure that 9 of 20 patients had discharge vital signs obtained and documented, per the facility's policy, prior to transfer from the hospital, to assess the patients' stability for transfer.


Tag A2409 Appropriate Transfer
The facility failed to ensure that the Certification Transfer Form contained required documentation to meet the requirements for an appropriate transfer for 12 of 20 patients.


2. The facility failed to have policies and procedures in place to address the requirements of ?489.24 and the related requirements at ?489.20.

a. A review of the facility's Medical Staff Bylaws and Medical Staff Rules and Regulations was conducted on 06/12/12. The bylaws and rules and regulations did not reflect any of the requirements of ?489.24 and the related requirements at ?489.20. The bylaws did not address the expectations of the medical staff members in the treatment of patients with emergency medical conditions nor did the bylaws address the expectations of medical staff members in effecting appropriate transfers of patients that complied with the EMTALA requirements at ?489.24 and ?489.20.

b. A review of the facility's policies and procedures was conducted from 06/12/12 through 06/14/12. The facility did not have policies/procedures that addressed on-call physician requirements for all emergencies (the facility did have a policy to address on-call response for traumas). The facility did not have policies/procedures that addressed staff's responsibility of reporting suspected EMTALA violations found at ?489.20(m). The facility did not have policies/procedures that addressed whistleblower protections in regards to EMTALA found at ?489.24(e)(3). The facility did not have policies/procedures that addressed the facility's recipient hospital responsibilities found at ?489.24(f).

c. An interview with the facility's Risk Manager and the facility's Compliance Officer on 06/12/12 at 4:01 p.m. confirmed that the facility's Medical Staff Bylaws and Medical Staff Rules and Regulations did not address EMTALA. The facility's Compliance Officer stated that the facility had identified the lack of policies and procedures that addressed the facility's responsibilities under EMTALA during an audit recently and had drafted an all encompassing policy to address the various EMTALA requirements. S/he stated that the policy had not yet been approved.

Based on observations and staff interview the facility failed to post signage visual to all individuals entering the emergency department that specifies the rights of individuals with respect to examination and treatment of emergency medical conditions, as well as whether the facility participates in the Medicaid program under a State approved plan.
Findings:
1. Observations conducted at the main campus on 06/12/12 at 10:57 a.m. with the Director of the Emergency Department revealed that there was one sign in the lobby near the registration desk but no sign posted in the ambulance bay or inside ambulance bay door or anywhere else in the Emergency Department to be viewed by individuals who did not enter through the lobby.
2. An interview with the Director of the Emergency Department was conducted on 06/12/12 at 10:57 a.m. S/he confirmed that there was no signage posted inside the Emergency Department that could be viewed by individuals that were brought in by ambulances or outside of the ambulance bay.

Based on staff interviews and review of medical records, policies/procedures and Medical Staff Bylaws, the facility failed to ensure that the required policies and procedures were in place that addressed specialty physician on-call availability/response expectations. The facility also did not have a policy that addressed circumstances in which the on-call specialist was unable to respond due to circumstances beyond his/her control.


Findings:

1. A review of the facility's Medical Staff Bylaws and Medical Staff Rules and Regulations was conducted on 06/12/12. The bylaws and rules and regulations did not reflect any of the requirements of EMTALA (Emergency Medical Treatment and Active Labor Act) requirements. The bylaws did not address the expectations of the medical staff members who would be functioning as on-call specialists providing support to the ED's, for the treatment of patients with emergency medical conditions.

2. A review of the facility's policies and procedures was conducted from 06/12/12 through 06/14/12. The facility did not have policies/procedures that addressed on-call physician requirements for all emergencies (the facility did have a policy to address on-call response for traumas).

3. Staff/Physician Interviews:

a. An interview with the facility's Risk Manager and the facility's Compliance Officer on 06/12/12 at 4:01 p.m. confirmed that the facility's Medical Staff Bylaws and Medical Staff Rules and Regulations did not address EMTALA. The facility's Compliance Officer stated that the facility had identified the lack of policies and procedures that addressed the facility's responsibilities under EMTALA during an audit recently and had drafted an all encompassing policy to address the various EMTALA requirements. S/he stated that the policy had not yet been approved.

b. During interviews with the Chief Medical Officer (CMO) on 06/14/2012 at 9:04 a.m. and again at 11:14 a.m. during the exit survey conference confirmed that they did not have all of the required policies/procedures to comply with EMTALA requirements, including the requirements related to on-call specialty physician responsibilities.

Based on interviews, record review and policy reviews, the Facility failed to provide an initial Medical Screening Exam (MSE), as is required by the Emergency Medical Treatment and Labor Act (EMTALA), for one (sample #18) of 20 medical records reviewed.

This failure created the potential that an emergency medical condition would be overlooked.

Findings:

1. Facility #1 did not provide a MSE by an attending physician, stabilization or properly completed transfer documents for Sample patient #18 prior to transferring the patient to another hospital for emergency care.

a.) Facility #1's policy titled EMTALA - Emergency Medical Conditions Offsite, revised December 2009 stated that any person who comes to the off-campus facility requesting emergency medical treatment will undergo a medical screening examination. The policy also states that after the MSE, the patient will be stabilized, appropriate transfer arranged and transfer paperwork and all documentation will be completed and sent with the patient.

b) Facility #1's policy "Screening for an Emergency Medical Condition," revised 4/2011, stated: "The medical screening examination will be performed by the [Emergency Department] (ED) attending or other member of the active medical or adjunct staff. The policy guidelines state that patients will not be 'triaged out' to other facilities, ED/urgent care or other areas of the hospital without [Medical Screening Exam] MSE. "

c) Facility #1's Policy Transfer of Patients to other Facilities revised 10/10 stated that the patient's medical or surgical condition must be evaluated and stabilized prior to transfer.

d) When queried about the procedure for transfers the The Medical Director of Facility #1's ED presented a policy, " MANAGEMENT OF THE PEDIATRIC TRAUMA PATIENT", written by Facility#2 that did not define an MSE requirement. She/he stated that this was the policy staff were following.

e) A review of Sample patient # 18's record revealed a six year old patient brought to the ED by the mother in a private vehicle on 03/20/12 at 6:28 p.m. The mother stated that the child fell 10-12 feet from a bouncy house onto a concrete surface landing on his/her head.

The patient was seen by a Registered Nurse (RN) at Facility #1 at 6:28 p.m. The RN documented that she/he contacted the triage RN at Facility #2 notifying them of a trauma alert patient at 7:35 p.m. The patient was transferred via wheelchair to the Facility #2's ED at 7:40 p.m.

The patient's ED record from Facility #1 did not contain a note from an attending physician or an MSE.

f) The Medical Director and the Clinical Manager for the Facility #1's ED were interviewed on 06/14/12 at 9:04 a.m. They stated that the triage RN would determine if the patient was stable. They also stated that Facility #1's ED physician would not normally be notified that a patient met trauma criteria and was being transferred to Facility #2 ' s ED.

g) The Chief Medical Officer from Facility #1's ED confirmed in an interview on 06/14/12 at 9:17 a.m. that no MSE was performed on this patient prior to transferring to Facility #2's ED.

Based on medical record review and staff interviews the facility failed to ensure that 9 of 20 patients had discharge vital signs obtained and documented, per the facility's policy, prior to transfer from the hospital, to assess the patients' stability for transfer.

Findings:

1. The facility did not ensure that patients who were seen in the Emergency Department and transferred from the facility to a receiving facility remained stable for transfer as evidenced in part by documented vital signs prior to transfer.

a) On 06/13/12, review of the facility's policy titled, "Nursing Assessment and Monitoring in the Emergency Department" dated 10/10 revealed that patients would receive a full set of vital signs within 30 minutes prior to transfer and that the vital signs would be communicated to the attending physician prior to transfer.

b) On 06/12/12 and 06/23/12 a review of 20 patient medical records was conducted. The records were of adults who were seen in one of the facility's Emergency Departments and were transferred to a receiving facility. 9 of 20 records did not contain documentation of vital signs obtained within 30 minutes prior to transfer (sample patients #2, #3, #4, #6, #7, #8, #10, #15, and #18) per the facility's policy.

c) On 06/13/2012 at 3:52 P.M. an interview was conducted with the Nursing Director of Emergency Department to confirm findings in the medical records for sample patients #1 through #10. The Director reviewed the records that did not contain documented vital signs within 30 minutes of transfer and agreed that this information was not present in the records. The Director stated that it was her/his expectation that vitals signs would be obtained and documented by nursing staff within 30 minutes of transfer, and reported to the attending physician, per the facility's policy.

Based on observations, interviews and record review, the facility failed to ensure that the Certification Transfer Form contained required documentation to meet the requirements for an appropriate transfer for 12 of 20 patients.
Findings:

1. A review of the facility's policy titled "Transfer of Patients to other Facilities" last revised 10/2010 stated:
"TCH (The Children's Hospital) transfer form must be completed in its entirety with one copy accompanying the patient and one copy to become part of the permanent medical record."

2. Medical record review of the certification "Transfer Form" for Sample Patients 1-20 on 6/13/12 revealed:

a. Sample record #1, section III was incomplete. The facility failed to document what medical record information was sent with the patient, the mode of transportation deemed appropriate and the qualified personnel who accompanied the patient. These findings were confirmed by the Director of the Emergency Department (ED) for the main campus on 06/13/2012 at 3:42 p.m..

b. Sample record #2, section II requires a dated, witnessed signature of the patient or legal guardian acknowledging that the risks and benefits of transfer have been explained by the physician. The witness signature did not have a date. Section III was missing documentation about what medical record information was sent to the receiving facility. Section IV the certifying physician did not include the date with his/her signature. These findings were confirmed by the Director of the Emergency Department (ED) for the main campus on 06/13/2012 at 3:42 p.m..

c. Sample record #3, section III the facility failed to document the mode of transportation deemed appropriate and the qualified personnel who accompanied the patient. In section IV risk/benefit was not completed. These findings were confirmed by the Director of the Emergency Department (ED) for the main campus on 06/13/2012 at 3:42 p.m..

d. Sample record #5, section III the facility failed to document the mode of transportation deemed appropriate and the qualified personnel who accompanied the patient. These findings were confirmed by the Director of the Emergency Department (ED) for the main campus on 06/13/2012 at 3:42 p.m..

e. Sample record #6, section II the signature acknowledging that the risks and benefit of transfer were explained by the physician did not have a witness signature. These findings were confirmed by the Director of the Emergency Department (ED) for the main campus on 06/13/2012 at 3:42 p.m..

f. Sample patient #8, section II the signature acknowledging that the risks and benefits of transfer were explained by the physician did not have a witness signature. Section III did not have the name of receiving physician, documentation that the medical record was sent, mode of transportation deemed appropriate for the patient and the qualified personnel who accompanied the patient. Section IV, the certifying physician was signed by a physician doing a fellowship. When the findings in the record were brought to the director of the Emergency Department (ED) for the main campus in an interview she called Medical Director of all Emergency Services and confirmed that an attending physician must co-sign the signature of any physician that was doing a fellowship at the main campus. These findings were confirmed by the Director of the Emergency Department (ED) for the main campus on 06/13/2012 at 3:42 p.m..

g. Sample record #10, section II the signature, acknowledging that the risks and benefit of transfer were explained by the physician, did not have a witness signature. Section III did not have the name of the receiving physician or the qualified personnel who accompanied the patient during transfer. These findings were confirmed by the Director of the Emergency Department (ED) for the main campus on 06/13/2012 at 3:42 p.m..

h. Sample record #12, section III did not contain the name of contact or the name of the receiving physician at the receiving facility. These findings were confirmed by the Clinical Manager of the ED for Children's Hospital Colorado at St. Joseph's Hospital on 06/14/2012, 9:19 a.m..

i. Sample record #13, section III contained no documentation about what medical record information was sent to the facility and did not list the qualified personnel who accompanied the patient. Section IV benefits of transfer was not completed. These findings were confirmed by the Clinical Manager of the ED for Children's Hospital Colorado at St. Joseph's Hospital on 06/14/2012, 9:19 a.m..

j. Sample record #14, section II the transfer request was not checked off and the patient's family requested the transfer to another facility. Section III did not contain documentation if the medical record was sent and who accompanied the patient. These findings were confirmed by the Clinical Manager of the ED for Children's Hospital Colorado at St. Joseph's Hospital on 06/14/2012, 9:19 a.m..

k. Sample patient #15, section II the signature acknowledging that the risks and benefit of transfer were explained by the physician was not signed and did not have a witness signature. These findings were confirmed by the Clinical Manager of the ED for Children's Hospital Colorado at St. Joseph's Hospital on 06/14/2012, 9:19 a.m..

l. Sample patient #18's record did not have a transfer form. These findings, that no transfer form was completed, were confirmed with the Clinical Manager of the ED for Children's Hospital Colorado at Parker Adventist Hospital on 06/14/2012, 9:06 a.m.