HospitalInspections.org

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Based on interview and document review, the hospital failed to implement their policies and procedures for evaluation and treatment and the transfer of patients that presented for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to ensure patients receive a comprehensive medical screening examination by a qualified medical professional and stabilizing treatment prior to transfer or discharge risks poor health outcomes, injury, and death. Failure to obtain written consent for transfer places patients at risk for transferring without understanding the risk of harm and related benefits of transfer or their right to refuse the transfer.

Findings included:

1. The hospital failed to ensure that a patient received a medical screening exam before they left the emergency department (ED).

2. The hospital failed to provide evidence that consent to transfer was obtained prior to transferring patients to a higher level of care.

Cross-reference: Tags A-2406, A-2409
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Based on interview and review of documents, the hospital failed to implement its policies and procedures to provide a medical screening exam for a patient that came to the emergency department (ED) seeking emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA) for 1 of 25 patient records reviewed (Patient #1).

Failure to provide a medical screening exam for patients before they leave the ED places patients at risk for harm from an undiagnosed or untreated medical or psychological emergency.

Findings included:

1. Document review of the hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," reviewed 06/24/19, showed that all individuals seeking emergency services at the hospital would receive an appropriate medical screening exam from a physician, physician assistant (PA), or advanced registered nurse practitioner (ARNP) to determine the presence or absence of an emergency medical condition.

2. On 09/01/20, the investigator reviewed the medical records of 25 patients listed in the hospital ED department logs with visits dated between 03/01/20 and 08/31/20. Document review showed that Patient #1 presented to the ED on 03/02/20 at 1:56 AM in a hyperverbal state, requesting a change in a psychiatriac medication that was prescribed to him that day during an earlier ED visit. Review of the medical record showed that hospital staff completed the triage process at 2:01 AM on 3/02/20, and at 3:06 AM on 03/02/20, staff documented that the patient was dismissed and had left without being seen (LWBS).

3. On 09/01/20 at 11:20 AM, the investigator reviewed security services case report #PS2020-0628 dated 03/02/20 at 3:32 AM, with the ED Director (Staff #1) and the Director of Security Services (Staff #2). Document review showed:

a. On 3/02/20 at 2:45 AM, Patient #1 was observed by hospital security wearing headphones and screaming song lyrics while pacing through the ED lobby. Patient #1 exited the lobby as he was approached by a security officer and was immediately met by two more security officers.

b. Patient #1 was discharged from the ED 8 hours prior to his encounter with the security team, and when asked why he was there, Patient #1 began to raise his voice and stated that he was there for a psych evaluation. The security officer told Patient #1 that according to the ED nurse, he was waiting for a medication refill. Patient #1 became increasingly agitated as he argued with security staff about needing a psych evaluation, but he eventually "slipped" and said he needed a medicine refill.

c. Patient #1 could not control his movements and became more combative since he had been "caught in a lie." Patient #1 clinched his fists and lunged toward one of the security officers, but the officer immediately "took control of him" and began to escort him off the campus. As he was being escorted off campus, Patient #1 grabbed his escort by the belt, causing them both to tumble down the stairs. Neither party was injured.

d. Patient #1 stated that he was not leaving, but he was told by security that he was not welcome back. Patient #1 approached a fourth security officer, complaining that security had "kicked him out," and was told, "you should probably leave then." The patient was observed walking off hospital campus and did not return that night.

4. On 09/01/20 at 11:40 AM, the investigator interviewed the ED Director (Staff #1), the Director of Security Services (Staff #2), and the Risk and Accreditation Specialist (Staff #3). Staff #1 and Staff #3 confirmed that the patient should have had a MSE, and hospital staff did not follow the hospital's EMTALA policy for the patient identified above.
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Based on interview, medical record review, and review of hospital policies and procedures, the hospital failed obtain written consent for transfer for 3 of 5 patients transferred from the emergency department (ED) to a higher level of care (Patients #8, #19, and #20.)

Failure to obtain written consent for transfer places patients at risk for transferring without understanding the risk of harm and related benefits of transfer or their right to refuse the transfer.

Findings included:

1. Document review of the hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," policy #6544838, reviewed 06/24/19, showed that when the facility transfers patients to a higher level of care, the physician would inform the patient of the risks of transfer and obtain an informed consent for transfer.

Document review of the hospital policy titled, "Transfer of Patient to Another Facility," policy #8278332, reviewed 07/16/20, showed that when transferring patients to another hospital, the physician was to complete the patient transfer form and the patient or representative were to sign the consent to transfer.

2. On 09/01/20 at 2:30 PM, the investigator reviewed the medical records of 5 patients who came to the hospital's ED between 03/01/20 and 08/31/20 with conditions that warranted transfer to a higher level of care. Document review showed that hospital staff failed to obtain signatures consenting to transfer for 3 of 5 patients transferred (Patient #8, 19, and #20).

3. On 09/01/20 at 10:45 AM, the investigator interviewed an ED physician (Staff #4). Staff #4 stated that in order to comply with EMTALA regulations, when transferring patients to a higher level of care, the hospital must ensure that the patient is stable for transport, provide a physician-to-physician and nurse-to-nurse hand-off between the sending and receiving hospital, and obtain written consent from the patient or family member.

4. During an interview with the ED Director (Staff #1) on 09/01/20, Staff #1 stated that hospital staff were supposed to obtain written consent when transferring patients to other hospitals. Staff #1 stated that if a patient or family member was unable to sign the consent form, staff would document, "Unable to Sign," and two staff members would sign the form verifying that the patient or family member provided verbal consent to the transfer. Staff #1 confirmed that hospital staff did not follow policy, and Patients #8, #19, and #20 did not have evidence that consent to transfer was obtained prior to transfer.

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