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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement, as defined in §489.24, related to Emergency Medical Treatment and Labor Act (EMTALA) requirements.

Findings:

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

Tag C2409 Appropriate Transfer- Based on interviews and document review, the facility failed to provide evidence of compliance of Emergency Medical Treatment and Labor Act (EMTALA) for the transfer of psychiatric patients to an accepting facility in four of four psychiatric transfer records reviewed (Patients #8, #9, #12 and #20). Additionally, the facility failed to ensure a provider signed the certification of medical necessity for one of ten medical records in which the patient was transferred to an outside facility (Patient #5).

Based on interviews and document review, the facility failed to provide evidence of compliance of Emergency Medical Treatment and Labor Act (EMTALA) for the transfer of psychiatric patients to an accepting facility in four of four psychiatric transfer records reviewed (Patients #8, #9, #12 and #20). Additionally, the facility failed to ensure a provider signed the certification of medical necessity for one of ten medical records in which the patient was transferred to an outside facility (Patient #5).

Findings include:

Facility policy:

The EMTALA Guidelines for Emergency Room, revised on 8/1/20 read, if a patient is to be transferred for medical necessity, the following guidelines must be followed: a physician must certify that the benefits of transferring outweigh the risks and the individual risks must be documented. Additionally, there must be documentation that the accepting hospital has accepted the patient prior to transfer.

References:

The EMTALA Consent Form read, I certify the risks of transfer, which is to be signed by the physician. Additionally, the consent form has a space to document the reason for transfer and the accepting hospital information. The form also has an area for the documentation of the mode of transport and the patient's consent prior to transfer.

1. The facility failed to ensure compliance with EMTALA was documented for patients who were transferred.

a. Medical Record Review revealed no completed EMTALA forms. The missing forms would include documentation of the following: risks and benefits of the transfer, documentation of accepting facility and physician, and physician certification pertaining to the reason for transfer.

i. On 12/31/19 at 2:41 p.m., Patient #8 went to the emergency department (ED) for a suicide attempt. The medical record revealed the patient was transferred to an outside psychiatric hospital. Upon review, there was no evidence of EMTALA paperwork or documentation in the patient's medical record to indicate compliance with EMTALA including the patient's consent to transfer and the medical necessity for transfer.

ii. On 3/11/20 at 8:03 a.m., Patient #9 went to the ED for a drug overdose. The medical record revealed the patient was transferred to an outside facility. Upon review, there was no evidence of EMTALA paperwork or documentation in the patient's medical record to indicate compliance with EMTALA including the patient's consent to transfer and the medical necessity for transfer.

iii. On 1/18/21 at 9:29 p.m., Patient #12 went to the ED for a suicide attempt. The record revealed the patient was transferred to an outside psychiatric hospital. Upon review, there was no evidence of EMTALA paperwork or documentation in the patient's medical record to indicate compliance with EMTALA including the patient's consent to transfer and the medical necessity for transfer.

iv. On 7/10/20 at 5:50 p.m., Patient #20 went to the ED for suicidal ideation. The record revealed the patient was transferred to an outside psychiatric hospital. Upon review, there was no evidence of EMTALA paperwork or documentation in the patient's medical record to indicate compliance with EMTALA including the patient's consent to transfer and the medical necessity for transfer.

b. On 1/26/21 at 1:00 p.m., the EMTALA documentation missing from the patients' medical records or evidence of risks and benefits of the transfer, documentation of accepting facility and physician, and physician certification pertaining to the reason for transfer was requested from the facility. The facility was unable to provide evidence of EMTALA compliance for Patient #8, #9, #12 and #20.

c. Interviews

i. On 1/26/21 at 1:10 p.m., an interview was conducted with Registered Nurse (RN #1). RN #1 stated any patient who was transferred to another facility from the ED needed to have EMTALA documentation completed. She stated this included patients who needed psychiatric treatment. RN #1 stated it was important for the EMTALA forms to be completed in order to show the patient had been evaluated and stabilized prior to transfer.

ii. On 1/26/21 at 1:04 p.m., an interview was conducted with the Director of Quality, Risk and Compliance (Director #2). Director #2 stated all patients, including psychiatric patients, needed EMTALA forms completed for transfer. Director #2 stated completed EMTALA forms were necessary and important to indicate the patient had received a medical screening exam and had been stabilized prior to transfer. Director #2 was unable to explain why the EMTALA forms were not completed for Patient #8, #9, #12 and #20.

iii. On 1/26/21 at 2:01 p.m., an interview was conducted with the Chief Nursing Officer (CNO #3). CNO #3 stated completed EMTALA forms were important to document risks and benefits had been discussed with the patient and to provide evidence the transfer was appropriate. CNO #3 was unaware the paperwork had not been completed for Patient #8, #9, #12 and #20.

2. The facility failed to ensure a provider completed the provider certification of medical necessity on EMTALA forms.

a. Record Review

i. On 12/27/20 at 11:25 a.m., Patient #5 went to the ED for abdominal pain. The medical record revealed the patient was transferred to an outside facility for treatment. Review of the patient's EMTALA forms revealed the provider certification of medical necessity for transfer was signed by a Registered Nurse (RN). The RN had received a verbal order from the provider, but the provider had not signed the verbal order.

b. Interviews

i. On 1/26/21 at 9:14 a.m., an interview was conducted with RN #4. RN #4 stated if a verbal order was received for the provider certification of a transfer, the provider must sign the order to certify the medical necessity of the transfer. RN #4 stated it was important for the provider to cosign the verbal order because a nurse did not have the authority.

ii. On 1/26/21 at 8:50 a.m., an interview was conducted with Chief Nursing Officer (CNO) #3. CNO #3 stated if a RN received a verbal order, the order must be signed by a provider. CNO #3 stated it was important for providers to sign verbal orders because the provider was ultimately responsible for the order and to ensure the communication was correct. CNO #3 stated no process was in place to ensure EMTALA forms were completed and signed by the provider.