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Based on reviews of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases.

FINDINGS INCLUDE:

The hospital failed to document a Medical Screening Examination (MSE) to a patient who was taken to the Emergency Department (Patient #1).

The hospital failed to document a Transfer of a patient to another facility on the Transfer Log. (Patient #1)

The hospital failed to contact the receiving facility and receiving physician for agreement to accept patient to their facility. (Patient #1)

The hospital failed to follow their own ED Escalation procedure. The physician called 911 before receiving the approval of the CNO or CEO.

The hospital failed to refer to the On-Call list for assistance for evaluation and/or treatment to stabilize a patient with an emergency medical condition. (Patient #1)

Patient #1's complete medical record was requested on 04/20/2023. Review of the medical record revealed no evidence of transfer documentation present in the medical record.

Employee #5 provided the ED Escalation Procedure for [(Arizona General Hospital) AGH]. Employee #5 confirmed this is the document that is used when further assistance is needed by ED staff and providers.
Employee #9 confirmed during an interview conducted on 04/24/2023 that they told the PAR (patient access representative/registration) to call Employee #5 (House Supervisor) in response to the Code Blue and in accordance to the ED Escalation Procedure. Employee #9 further confirmed that Provider #4 said to call 911 for assistance. Employee #9 confirmed that two codes happened on 03/18/2023. Employee #9 further confirmed that it was the first time that multiple codes happened concurrently in one evening. Employee #9 confirmed that the ED was busy and all 9 rooms were occupied with patients at the time Patient #1 arrived to the ED.

Based on review of policies and procedures, medical records and staff interviews, it was determined that the hospital failed to ensure the medical record was complete with all required documentation for one (1) patient (Patient #1).


FINDINGS INCLUDE:

Hospital policy titled, "Dignity Health Emergency Medical Care/Emergency Medical Treatment and Labor Act (EMTALA) Corporate Policy", revealed " ...I SCREENING AND STABILIZATION REQUIREMENTS A. Medical Screening Examination ...1. Scope of Examination. A Medical Screening Examination is the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether an Emergency Medical Condition exists. The scope of the examination must be tailored to the presenting complaint and the medical history of the individual. The process may range from a simple examination to a complex examination ...A medical record documenting the history and physical examination ...will be created to document the screening exam ...E. Transfer of Individuals with an Emergency Medical Condition ...2, Requirements for an Appropriate Transfer ...a. The hospital provided medical treatment within its capacity to minimize the risks to the individual's health and, in the care of a women in labor, the health of the unborn child; the medical record will reflect the vital signs and condition of the individual at the time of transfer ...c. The hospital sends to the receiving facility all medical records (or copies thereof) available at the time of transfer related to the emergency medical condition of the individual, including (i) records related to the individual's emergency condition; (ii) the individual's informed written consent to transfer or the physician certification ..."

Review of Patient #1 medical record from Hospital #1 revealed no documentation of Patient #1 being triaged or having a medical screening examination. Further review of Patient #1 medical record from Hospital #1 revealed no evidence of documentation of vital signs or condition of Patient #1 at time of transfer to Hospital #2. Further review of Patient #1 medical record revealed no evidence of required transfer documentation present in the medical record.
Review of Patient #1 ED Discharge Note dated 03/18/2023, revealed " ...Discharge Depositions: Transferred to another Acute Care Facility ...Transfer to Another Faculty ...Accepting facility Hospital #2 [Banner Ironwood ER] ...."

Hospital #2 was contact on 04/27/2023 for Patient #1's complete medical record for 03/18/2023. RH #1 from Hospital #2 confirmed in electronic mail that there is no record of Patient #1 being transferred to Hospital #2 on 03/18/2023.

Review of 19 additional ED patients' medical records randomly selected from the ED logs revealed all required documentation was present in each patient's medical record.

Employee #4 confirmed during a medical record review on 04/20/2023 that Patient #1 medical record was not complete.

Based on review of records, policies and procedures, hospital log/documents and staff interviews, it was determined the hospital failed to call the On-call physician to facilitate in stabilization of a patient during a medical emergency.

FINDINGS INCLUDE:

Hospital policy titled, "Dignity Health Emergency Medical Care/Emergency Medical Treatment and Labor Act (EMTALA) Corporate Policy", revealed: " ...On-Call List means the list of individual physicians (not physician groups) by specialty or special function who is "on-call" after the initial medical screening examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. The On-Call List is maintained by the hospital and posted in the Dedicated Emergency Department ....C. On-Call Response. The hospital will maintain a list of physicians, (physician group names are not acceptable for identifying the on-call physician), who are on-call to come to the hospital to consult or provide treatment necessary to stabilize an individual with an emergency medical condition. The on-call list will be maintained in a manner that best meets the needs of the individuals who are receiving emergency services in accordance with the resources available to the hospital, including the availability of on-call physician ...."

Hospital policy titled, "Emergency Scope of Services", revealed: ' ...Purpose ...The Purpose/Scope of the Emergency Department is to provide health care services to patients seeking emergency care ...without regard to their age, race, color, creed, national origin, immigration status ...Types and Ages of Patient Served ...The emergency department will provide emergent, urgent and non-urgent care to patients of all age groups. Specific age groups include: Neonate-Birth up to 1month Infant-1month up to 1 year Pediatric 1 year up to 14 years Adolescent-14 years up to 65 years Geriatric-65 years and older ...."

An On-Call list was provided for March 2023. Review of the On-Call List revealed a physician was available on the On-Call list for 03/18/2023.

Employee #4, #3 and #5 confirmed that one (1) medical provider, two (2) registered nurses (RNs), one (1) PAR (patient access representative/registration) and one (1) Radiologic Technologist were working on the evening of 03/18/2023. Employee #4, #3 and #5 further confirmed that this is the standard for the evening shift for this facility.
Employee #9 confirmed during an interview conducted on 04/24/2023 that they told the PAR to call Employee #5 (House Supervisor) in response to the Code Blue and in accordance to the ED Escalation Procedure. Employee #9 further confirmed that Provider #4 said to call 911 for assistance. Employee #9 confirmed that two codes happened on 03/18/2023. Employee #9 further confirmed that it was the first time that multiple codes happened concurrently in one evening. Employee #9 confirmed that the ED was busy and all 9 rooms were occupied with patients at the time Patient #1 arrived to the ED.

Provider #7 confirmed during an interview conducted on 04/20/2023 that they do not have a Pediatric Specialist on-call. Provider #7 further confirmed that if a pediatric specialist is needed they will call the local pediatric hospitals [Phoenix Children's Hospital or Banner Cardon] for assistance.

Based on review of policy and procedure, hospital documents and staff interview, it was determined the facility failed to document a patient presenting to the ED for examination and treatment on the dedicated ED log. (Patient #1)

FINDINGS INCLUDE:

Hospital policy titled, "Dignity Health Emergency Medical Care/Emergency Medical Treatment and Labor Act (EMTALA) Corporate Policy", revealed " ...General Policies ...B. Centralized Log. Each hospital will maintain one central log through the electronic health record that is inclusive of all required elements: name of individual, date/time of arrival, and disposition type per federal regulations; means of arrival per Arizona ...."

A request was made for the dedicated ED log for January, February and March of 2023 was made on 04/2023. Review of the ED log on 04/20/2023 revealed no documentation of Patient #1 on the ED log for 03/18/2023. A second request was made for the dedicated ED log for 03/18/2023. Review of the ED log provided revealed no documentation of Patient #1 on the ED log. A third request was made on 04/24/2023 for the dedicated ED log. A review of the ED log provided revealed documentation of Patient #1 on the log for 03/18/2023.

Employee #3 and #1 confirmed that Patient #1 was not on the first two (2) ED logs provided to the surveyor. Employee #3 confirmed that Patient #1 was in the facilities electronic medical record system. Employee #3 confirmed that they were going to have IT (information technology) correct this discrepancy.

Based on review of policies and procedures, hospital documents and staff interviews, it was determined that the hospital failed to document that a Medical Screening Examination was provided to a patient who presented to the ED for examination and treatment of an Emergency Medical Condition (EMC). (Patient #1)

FINDINGS INCLUDE:

Patient #1 presented to Hospital #1's Freestanding Emergency Department (ED) on 3/18/2022 at 03:23, carried into the ED by [their mother] who was performing rescue breaths on the patient. Upon arrival to the facility a code blue was called for Patient #1 and CRP (cardiopulmonary resuscitation) was initiated by ED staff. At the time of Patient #1's arrival to the ED, an EMS (emergency medical service) crew was in the facility assisting with another code for another patient, Patient #2. The EMS crew assisted the provider with resuscitative efforts for Patient #1. Once ROSC (return of spontaneous circulation) was received EMS transport Patient #1 to Hospital #2 [Banner Ironwood].

Hospital policy titled, "Dignity Health Emergency Medical Care/Emergency Medical Treatment and Labor Act (EMTALA) Corporate Policy", revealed: " ...I . SCREENING AND STABILIZATION REQUIREMENTS ... A. Medical Screening Examination All individuals who come to a DED (Dedicated Emergency Department) of the hospital (whether on campus or off campus) for examination or treatment, and all individuals who present on hospital property requesting examination or treatment of an Emergency Medical Condition shall receive an appropriate Medical Screening Examination or necessary stabilizing treatment in order to inquire about an individual's ability to pay or to inquire about eligibility for financial assistance under the hospital's Financial Assistance Policy 1. Scope of Examination. A Medical Screening Examination is the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether an Emergency Medical Condition exists. The scope of the examination must be tailored to the presenting complaint and the medical history of the individual ...A medical record documenting the history and physical examination, and any special reports such as consultation, clinical laboratory, diagnostic imaging, and the like, will be created to document the screening exam ...."

Hospital policy titled, "Emergency Department Standards of Care", revealed: " ...Triage Screening: An RN will complete a triage screening, including a triage acuity score on patients presenting to the emergency department as quickly as possible. During screening, the RN will determine if the presenting patient required immediate life-saving intervention ...."

Patient #1 Emergency Documentation Physician Note dated 03/18/2023 revealed: " ... Patient #1 arrived to the ED, carried by [parent], into facility at 0323 ...." Further review revealed no evidence of documentation that Patient #1 was triaged, given an ESI or had a medical screening examination (MSE) by a QMP. Further review revealed Patient #1's final disposition was listed as transferred.

Patient #1's Code Blue documentation dated 03/18/2023 revealed, compressions and ventilation were performed immediately at 0322. Defibrillation was administered at 0323. Epinephrine was given at 0322, 0324, 0325, and 0328.

Further review of Patient #1's Code Blue documentation revealed, EMS arrived to assist at 0327 and assumed care at 0330. Patient #1 was at ROSC at 0337 and was transferred to Hospital #2 [Banner Ironwood].

Review of 19 additional medical records of patients randomly selected from the ED Logs revealed documentation of triage with ESI and MSE was present. Further review revealed triage time and MSE were documented in the medical records of the patients that were experiencing cardiac arrest or resuscitative measures at time of presentation to the ED.

Employee #4 confirmed on 04/20/2023 that during record review that triage time, ESI and time of MSE by QMP was not documented due a Code Blue being activated. Employee #5 further stated that all documentation during a code blue is written on the Code Blue Documentation sheet.

Employee #9 confirmed during an interview conducted on 04/24/2023 that they told the PAR to call Employee #5 (House Supervisor) in response to the Code Blue and in accordance to the ED Escalation Procedure. Employee #9 further confirmed that Provider #4 said to call 911 for assistance. Employee #9 confirmed that two codes happened on 03/18/2023. Employee #9 further confirmed that it was the first time that multiple codes happened concurrently in one evening. Employee #9 confirmed that the ED was busy and all 9 rooms were occupied with patients at the time Patient #1 arrived to the ED.
Employee #5 confirmed during medical record review on 04/20/2023, that 911 was called to assist with Patient #1. Employee #5 further confirmed that is EMS is called, EMS will decide which facility the patient is transferred to.

Based on review of medical records, policies and procedures, hospital documents, and staff interview, it was determined the hospital failed to provide stabilizing treatment to a patient before transferring the patient to another facility. (Patient #1)

FINDINGS INCLUDE:

Hospital policy titled, "Dignity Health Emergency Medical Care/Emergency Medical Treatment and Labor Act (EMTALA) Corporate Policy", revealed: " ...EMS and stabilizing treatment will be provided to all individuals presenting at Dignity Health Dedicated Emergency Departments (DED) requesting examination or treatment of a medical condition ...."

Patient #1's ED Physician note dated 03/18/2023 revealed, " ...Medical Decision Making ...We immediately called a code. Patient was in asystole on the monitor. I bagged the patient as a nurse began CPR. Patient was intubated ...Bagging continued with 100% oxygen. There was color change on the inline CO2 detector and equal breath sounds bilaterally with bagging. CPR was done continuously while pulseless by nurse or automated CPR device. I established an IO inferior to the anterior medial tibial plateau and immediately pushed 1 mg of epinephrine. At this point patient had a faint palpable pulse and a sinus tachycardia on the monitor. We had called [Gilbert Fire] since we had 2 codes at this time and as soon as we had pulses they loaded this patient and transported [her] ...."

Patient #1's Code Blue Documentation dated 03/18/2023 revealed treatment was initiated at 0322. Further review of Patient #1's Code Blue documentation revealed, EMS arrived to assist at 0327 and assumed care at 0330. Patient #1 was at ROSC at 0337 and was transferred to Hospital #2 [Banner Ironwood].

Further review of the Code Blue Documentation revealed Provider #4, Employee #15, Employee #9 and Employee #16 signed off on the Code Blue Document as assisting in Code Blue.

A random sample of 19 ED records of patients who were transferred to another facility for care were reviewed. There was documentation in all of the records that stabilization treatment was provided when applicable prior to the transfer.

Based on review of records, policies and procedures, hospital log/documents and staff interviews, it was determined the hospital failed to perform transfer with the appropriate documentation for a patient requiring a higher level of care. (Patient #1)

FINDINGS INCLUDE:

Hospital policy titled, "Dignity Health Emergency Medical Care/Emergency Medical Treatment and Labor Act (EMTALA) Corporate Policy", revealed: " ...E. Transfer of Individuals with an Emergency Medical Condition ...2. Requirements for an Appropriate Transfer ...a. The hospital provides medical treatment within its capacity to minimize the risks to the individual's health ...the medical record will reflect the vital signs and condition of the individual at the time of the transfer; and b. The receiving facility has available space and qualified personnel for treatment of the individual; and the receiving facility and receiving physician have agreed to accept the individual and to provide appropriate medical treatment; and c. the hospital sends to the receiving facility all medical records (or copies thereof) available at the time of transfer related to the emergency medical condition of the individual, including (i) records related to the individual's emergency condition ...."

Patient #1's medical record revealed no evidence of the required transfer documents.

Review of the Transfer Log from March 2023 revealed no evidence of Patient #1 was having been documented on the log.

Employee #4 confirmed during a medical record review on 04/20/2023 that Patient #1 transfer paperwork was not in the medical record. Employee #5 further confirmed during medical record review on 04/20/2023, that 911 was called to assist with Patient #1. Employee #5 further confirmed that is EMS is called, EMS will decide which facility the patient is transferred to.