HospitalInspections.org

Based on a review of policies and procedures, medical records, and interviews with staff, the critical access hospital (CAH) failed to:
1. ensure staff followed the CAH's EMTALA policies requiring staff to complete a Qualified Medical Professional (QMP) or physician report to the receiving facility QMP (physician) and explain risks and benefits of the transfer of 4 of 7 sampled mental health patients requiring transfer from the CAH's ED (Emergency Department) to acute care hospitals for patient records reviewed from 9/24/14 to 2/16/15 (Patient #1, 3, 4 and 10); and

2. ensure CAHs obstetric staff followed the CAH's EMTALA policies requiring OB staff to maintain a complete OB log for 2 of 2 sampled OB patients that presented to the CAH with emergency medical conditions and were transferred to acute care hospitals (Patients #19 and 20).

Failure of the sending hospital to complete a QMP report for the receiving hospital physicians and to explain risks and benefits to ED patients with emergency medical conditions that necessitated transfer to acute care hospitals could result in a delay in care for the transferred patients after arrival at the recipient hospitals. Failure to maintain a complete OB log that included all OB patients presenting to the CAH ED or the OB department of the CAH resulted in the lack of a system to track those OB patients who were not admitted and delivered a baby.

According to information obtained from the CAH at the time of the investigation, the CAH furnished emergency services to an average of 285 patients per month in the ED or other areas of the hospital. The average number of patients receiving emergency care in the OB department was not tracked by the OB staff and was not known.

Findings include:

1. Review of the hospital policy and procedure titled "Emergency Medical Treatment and Active Labor Act (EMTALA)," effective date 11/25/2014, revealed in part... "3. d. Ensures that the transfer is affected through qualified personnel and transportation equipment, as required including the use of necessary and medically appropriate life support measures during transfer. The physician is responsible for determining the appropriate mode of transport, equipment and transporting professionals to be used for the transfer. Refer to C-2409.

2. Review of the hospital policy and procedure titled "Emergency Medical Treatment and Active Labor Act (EMTALA)," effective date 11/25/2014, revealed in part... Record Keeping: c. a log on each individual who comes to the ED, L&D (Labor and Delivery) will be maintained. The log includes an indication whether the individual refused treatment or transfer, or was transferred, admitted and treated, stabilized and transferred or discharged." Refer to C-2405.

Based on a review of policy and procedures, medical record documentation, and the OB (Obstetric) log and interview with staff, the Critical Access Hospital (CAH) failed to ensure the OB log included 2 of 2 sampled OB patients treated, stabilized, and transferred to a hospital for OB medical records reviewed from 9/24/14 to 2/16/15 (Patient #19 and 20). The OB department was not able to provide an average number of OB patients with unscheduled appointments for medical care related to pregnancy because there was not a system in place to track those OB patients.

Failure to maintain a complete OB log for all OB patients presenting to the CAH's emergency department or presenting to the OB department directly seeking emergency care resulted in the inability of the CAH to provide a list for OB patients seeking care for reasons other than the admission and delivery of a baby.

Findings include:

1. The CAH's policy and Procedure titled. Emergency and Medical and Active Labor Act (EMTALA) included the following information. "Pregnant women who come to the Emergency Department (ED) or who come to another area of the hospital seeking unscheduled medical treatment related to pregnancy are immediately transported in an appropriate manner to the labor and delivery department (if available), which functions as an extension of the ED for purposes of providing the screening examinations, stabilizing treatment and appropriate transfers."
Review of the hospital policy and procedure titled "Emergency Medical Treatment and Active Labor Act (EMTALA)," effective date 11/25/2014, revealed in part... "Record Keeping: c. a log on each individual who comes to the ED, L&D (Labor and Delivery) will be maintained. The log includes an indication whether the individual refused treatment or transfer, or was transferred, admitted and treated, stabilized and transferred or discharged."

2. Review of the OB log on 2/16/15 at 11:30 AM revealed there was no documentation entered on the log for Patients #19 and 20. The OB staff recalled these two patients presenting to the OB Department for emergency medical screening and treatment. The OB log documentation included only the patients presenting to the OB department requiring admission to the CAH and delivery of a baby. The OB log lacked documentation for OB patients presenting to the OB department and receiving emergency medical screening, stabilizing treatment, and discharged or transferred to another facility.

3. Review of the medical records for Patient #19 and 20 revealed they both presented to the OB department, were evaluated, stabilized and transferred to hospitals for a higher level of care.

Review of the medical record for Patient #19 revealed the patient was sent to the OB department after a routine office visit on 12/31/13 with a complaint of a slight amount of vaginal bleeding, very small amount on the tissue. The patient had some dull cramps with some Braxton Hicks (contractions occurring before real labor), but nothing significant. In the OB department, Patient #19 had contractions every 2 to 4 minutes and was not responding to two doses of Terbutaline, a medication used to stop or prevent premature labor. The patient was given a booster dose of Progesterone, a steroid hormone involved in the menstrual cycle. The patient's cervix was dilated 2 to 3 cm (centimeters) and was 50% effaced at 0 station. The patient had an intrauterine pregnancy at 33 and 4/7 weeks gestation with threatened preterm labor. The patient was transferred to a higher level of care hospital.

Review of the medical record for Patient #20 revealed the patient presented to the OB department on 7/25/14 with an elevated blood pressure while pregnant. The patient was 44 years old and at 30 weeks gestation with a history of recurrent miscarriages. The patient checked her blood pressure at home and it was elevated. The patient also complained of intermittent headaches. The patient was a high risk pregnancy with uncontrolled blood pressure. The patient was given Labetolol and Hydralazine, medications for high blood pressure, and transferred to a hospital for a higher level of care.

4. During an interview on 2/16/15 at 11:30 AM, Staff A, OB Manager stated staff only document patients presenting to the OB department requiring admission to the CAH and delivering a baby. Staff do not document patients evaluated in the OB who are evaluated, stabilized and discharged home or transferred to another facility.

During an interview on 2/17/15 at 10:00 AM, Staff B, Registrar stated the OB nurse is contacted for OB patients presenting for evaluation and treatment. The OB patients are not referred to the emergency department, only the OB department.

During an interview on 2/17/15 at 10:05 AM, Staff C, Registrar stated the OB nurse is contacted for OB patients presenting for evaluation and treatment. The OB patients are not referred to the emergency department, only the OB department.

Based on a review of EMTALA policies and procedures, medical record documentation, and staff interviews, the Critical Access Hospital (CAH) failed to ensure the physician or midlevel practitioner verbally contacted the recipient hospital for acceptance and explained the risks and benefits of the transfer to 4 of 7 mental health patients transferred from the CAH ED (Emergency Department) to a hospital between 9/24/14 to 2/16/15 (Patient #1, 3, 4, and 10).

Failure to ensure the sending physician or midlevel practitioner verbally contacted the recipient hospital regarding the condition or status of the patient being transferred could result in the transfer of patients to a facility without the capability to provide effective care and support to treat the EMC (Emergency Medical Condition) of the patient.

Failure of the physician or midlevel to explain the risks and benefits to the ED patients requesting or requiring a transfer could result in the patients not understanding complications that could potentially occur during the transfer.

Findings include:

1. Review of the hospital policy and procedure titled "Emergency Medical Treatment and Active Labor Act (EMTALA)," effective date 11/25/2014, revealed in part... "3. d. Ensures that the transfer is affected through qualified personnel and transportation equipment, as required including the use of necessary and medically appropriate life support measures during transfer. The physician is responsible for determining the appropriate mode of transport, equipment and transporting professionals to be used for the transfer."

2. The CAH's Transfer Summary and Consent Form included a section for the explanation of risks and benefits and a section for the communication with receiving physician and transferring information. The medical records of Patients #1, 3, 4, and 10 lacked a completed copy of this form.

3. Review of the medical record for Patient #1 revealed the patient presented to the ED on 2/3/2015 with a complaint of suicidal ideation. Practitioner A, a physician, evaluated the patient and obtained a court order for a mental health committal and inpatient psychiatric services. The medical record lacked documentation of a physician to physician report for the recipient hospital and an explanation of risks and benefits of the transfer to the patient. The medical record lacked the CAHs Transfer Summary and Consent Form.

Review of the medical record for Patient #3 revealed the patient presented to the ED on 1/31/2015 with a complaint of suicidal ideation. Practitioner F, a physician, evaluated the patient and obtained a court order for a mental health committal to inpatient psychiatric services. The medical record lacked documentation of a physician to physician report for the recipient hospital and an explanation of risks and benefits of the transfer to the patient. The medical record lacked the CAHs Transfer Summary and Consent Form.

Review of the medical record for Patient #4 revealed the patient presented to the ED on 1/30/15 with a complaint of suicidal ideation. Practitioner F evaluated the patient and obtained a court order for a mental health committal to inpatient psychiatric services. The medical record lacked documentation of a physician to physician report for the recipient hospital and an explanation of risks and benefits of the transfer to the patient. The medical record lacked the CAHs Transfer Summary and Consent Form.

Review of the medical record for Patient #10 revealed the patient presented to the ED on 12/5/14 with a complaint of suicidal thoughts. Practitioner G, a Physician Assistant, evaluated the patient and obtained a court order for a mental health committal to inpatient psychiatric services. The medical record lacked documentation of a physician to physician report for the recipient hospital and an explanation of risks and benefits of the transfer to the patient. The medical record lacked the CAHs Transfer Summary and Consent Form.

4. During an interview on 2/17/15 at 7:30 AM, Staff E, a Registered Nurse (RN) in the ED, reported the ED staff did not obtain a physician to physician report and explain risks and benefits to Patient #1 before the patient transferred to the recipient hospital. Staff A said the nurse calls for bed placement and an accepting hospital for mental health patients. After the nurse to nurse report is completed and the nurse at the receiving hospital accepts the patient, the patient is transferred. The physician generally does not communicate with the receiving facility physician.

During an interview on 2/17/15 at 8:15 AM, Practitioner A stated she did not complete a physician to physician report and explain risks/benefits to Patient #1 when transferred to another facility. Practitioner A said she fell asleep while the nurse found bed placement at an accepting hospital. The physician does not generally communicate with the receiving hospital because the nurses at the receiving hospital state they are qualified to accept the transfer for the receiving hospital physicians.

During an interview on 2/16/15 at 1:00 PM, Staff D, RN confirmed the medical records for Patients #1, 3, 4 and 10 lacked documentation of a physician to physician report and staff explaining risks/benefits to the patients prior to transfer to another facility. This should be completed for an appropriate transfer.

During an interview on 2/17/15 at 8:30 AM, Staff G, RN ED Manager confirmed the medical records for Patient #1, 3, 4 and 10 lacked documentation for a physician to physician report and staff explaining risks/benefits to the patients prior to transfer to another facility. This should be completed with all transfers, including mental health patients.

During an interview on 2/17/15 at 8:45 AM, Practitioner B, ED Medical Director stated all transfers require a physician to physician report to obtain an accepting physician, explanation of risks/benefits and a nurse to nurse report to confirm an available bed. This process is the same for both medical and mental health transfers.