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Based on document review and interview, the facility failed to maintain a central log of ED patients (see tag 2405), failed to ensure documentation indicating an MSE was performed (see tag 2406), failed to ensure a physician certification of the risks and benefits of patient transfer to a facility with additional treatment capabilities (see tag 2409), failed to ensure an accepting physician had agreed to provide medical treatment for the patient upon transfer to the receiving facility with available space and personnel (see tag 2409), and failed to ensure copies of all medical records related to the presenting EMC were sent with the patient at or around the time of transfer (see tag 2409).

Findings include:

1. See findings cited at 489.20(r)(3) A2405, 489.24(1) A2406, 489.24(e)(ii)(B), 489.24(e)(2)(ii), and 489.24(e)(2)(iii) A2409.

Based on document review and interview, the facility failed to maintain a central log of each individual that comes to the ED (Emergency Department) seeking assistance and medical care including documentation indicating whether the patient refused treatment, or was refused treatment, or was transferred to another facility, or admitted to the facility and treated, or stabilized and transferred to another facility, or discharged for 15 of 21 medical records (MR) reviewed (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 14, 15, 16, 18, 20 and 21).

Findings include:

1. Review of the policy/procedure EMTALA: Emergency Medical Screening, Stabilization, and Transfer (approved 1-17) indicated the following: "The Hospital must maintain a central log on each individual who comes to the ED seeking assistance and indicate in the log whether he or she refused treatment, was refused treatment or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged."

2. Review of facility administrative documentation titled MIS Discharge Disposition Dictionary indicated a listing of the discharge disposition identifiers used with the ED Logs (Patient Registers) requested on entrance for sample selection of ED medical records to review.

3.Review of the ED logs for the period 10-1-17 through 4-20-18 indicated the disposition code identifier "STH" (the disposition name of 02 Acute Hospital was observed on the MIS Discharge Disposition Dictionary) was entered under the disposition header for ED patients that were admitted to the facility as well as for ED patients that were transferred (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9 and 18) to another acute care facility. The ED logs failed to indicate a discharge disposition code for Patients #14, 15 or 16, or indicate Patient #20 was discharged to home, or indicate Patient #21 left before being seen and signed out AMA as identified during the MR review.

4. On 4-23-18 at 1520 hours, staff A2 confirmed the April 2018 ED log area for recording the patient disposition failed to clearly indicate if Patient #2 was transferred or admitted by the entry code STH (acute care hospital).

5. On 4-24-18 at 1225 hours and 1730 hours, staff A2 confirmed the ED logs lacked documentation indicating Patients #1, 3, 4, 5, 6, 7, 8, 9 or 18 were transferred to another acute care facility.

6. On 4-24-18 at 1235 hours, staff A2 confirmed the April 2018 ED log lacked documentation indicating the discharge disposition for Patients #14, 15 or 16.

7. On 4-24-18 at 1745 hours and 1800 hours, staff A2 confirmed the ED log failed to indicate Patient #20 was treated and discharged home and confirmed the ED log failed to indicate Patient #21 signed AMA documentation and left the ED without being seen by a medical provider as identified during the MR review.

Based on document review and interview, the facility failed to ensure documentation of a Medical Screening Exam (MSE) was readily available for all individuals seen in the Emergency Department (ED) for 1 of 11 transfer patient medical records (MR) reviewed (Patient #18).

Findings include:

1. Review of the Medical Staff Bylaws (approved 2-16) indicated the following: "Article IV: Categories of Medical Staff. Section 7a: Telemedicine Consulting Medical Staff... This category of privileges shall include Telemedicine privileges, which is the diagnosis and/or treatment of patients employing offsite telecommunications... The Telemedicine Consulting Medical Staff will be subject to the conditions of consultation as defined in the Rules and Regulations..."

2. Review of the Rules and Regulations of the Medical Staff (approved 2-16) indicated the following: "Emergency Medicine Services... G...Individuals presenting with psychiatric or chemical dependency symptoms may be given a medical screening exam by an Allied Mental Health Professional who [provides] services as "qualified medical personnel." H. An appropriate medical record shall be kept for every patient receiving emergency service and be incorporated in the patient's Hospital record..."

3. Review of the MR for Patient #18 indicated the psychiatric MSE was performed by a network Telemedicine Consulting Psychiatrist or Allied Health Professional (AHP) at the time of the ED visit and indicated the patient was transferred to an out-of-network facility #5078 inpatient psychiatric unit. Review of the MR for Patient #18 failed to indicate a copy of the telemedicine MSE or the name and qualifications of the Psychiatrist or AHP that performed the MSE, or indicate a copy of the MSE was sent with the patient upon transfer to the out-of-network facility.

4. On 4-24-18 at 1730 hours, staff A2 confirmed the MR for Patient #18 lacked documentation indicating a copy of the telemedicine psychiatric MSE, or indicating the name and qualifications of the consulting Psychiatrist or AHP that performed the MSE, or indicating a copy of the MSE was sent with the patient upon transfer to the out-of-network facility and confirmed no other documentation was available.

Based on document review and interview, the facility failed to ensure a physician certified the benefits and risks of patient transfer and obtained the consent of an accepting physician for all ED (emergency department) patients transferring to an accepting facility for 1 of 21 medical records (MR) reviewed (Patient #2) and failed to maintain documentation indicating the MR copies sent with the patient at the time of transfer for 10 of 21 MR reviewed (Patients 1, 2, 3, 4, 5, 6, 7, 8, 10 and 18).

Findings include:

1. Review of the policy/procedure EMTALA: Emergency Medical Screening, Stabilization, and Transfer (approved 1-17) indicated the following: "A physician certifies that the medical benefits reasonably expected from the provision of medical treatment at another facility outweigh the risks to the individual... the physician must be documented on the Transfer Form and the physician must countersign the certification. All certifications must contain a summary of the risks and benefits to the individual... An appropriate transfer under EMTALA is one in which the hospital provides medical treatment within its capacity that minimizes the risk to the individual's health... is made to a facility that has available space and qualified personnel for the individual's treatment and has agreed to the transfer and to provide the appropriate medical treatment... the hospital sends copies of all medical records related to the presenting EMC [emergency medical condition] that are available at the time of transfer to the receiving facility and copies of any other records not available at the time of transfer to the receiving facility as soon as possible after the transfer..."

2. Review of the MR for Patient #2 lacked documentation indicating a physician certified the benefits of patient transfer outweighed the risks of transfer to a facility with available space and additional treatment capabilities, and/or indicating an accepting physician had agreed to provide medical treatment for the patient upon transfer to the receiving facility, and/or indicating copies of all medical records related to the presenting EMC were sent with the patient at or around the time of transfer.

3. On 4-23-18 at 1315 hours, staff A2 confirmed the MR for Patient #2 lacked documentation of a Transfer Form indicating MD11 certified the need for patient transfer to a facility with additional treatment capabilities or indicating a physician at the receiving facility agreed to provide medical treatment for the transfer patient.

4. Review of the MR for Patients #1, 2, 3, 4, 5, 6, 7, 8, 10 and 18 lacked documentation indicating the copies of MR documentation that were sent with the patient at the time of transfer or shortly afterwards.

5. On 4-24-18 at 1815 hours, staff A2 confirmed the MR for Patients # 1, 2, 3, 4, 5, 6, 7, 8, 10 and 18 lacked documentation indicating the MR copies that were sent with the patient to the receiving facility at or around the time of transfer.