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Based on tours/observations, staff interviews and review of medical records, policies/procedures and other facility documents, the facility failed to comply with the Medicare provider agreement as defined in ?489.20 and ?489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

Findings:

1. The facility failed to meet the following requirement under the EMTALA regulations:

Tag A 2402 - Posting of Signs
The facility failed to ensure EMTALA signage was posted throughout the facility and, instead, only had EMTALA signage posted in three locations. This failure did not ensure patients were fully informed of their rights with respect to examination and treatment of emergency medical conditions, as well as whether the facility participates in the Medicaid program under a State approved plan.

Tag A 2409 - Appropriate Transfer
The facility failed to ensure two of three patients transferred from the facility's emergency department were transferred with appropriate paperwork and documentation of EMTALA specific requirements.

Tag A 2411 - Recipient Hospital Responsibilities
The facility failed to accept transfer from a referring hospital when it had the capacity to treat the patient and was defined as a higher level of care.

Based on observation tour of the facility and staff interviews, the facility failed to ensure EMTALA signage was posted throughout the facility and, instead, only had EMTALA signage posted in three locations. This failure did not ensure patients were fully informed of their rights and created the potential for a negative outcome.

Findings:

1. The facility failed to post EMTALA signage in a place or places likely to be noticed by all individuals entering the emergency department or obstetrics unit as well as those waiting for treatment. Specifically, the facility failed to post EMTALA signage at the entrance, admitting area, and treatment areas of both the emergency department and the maternal unit. Additionally, the facility failed to have signage posted at the ambulance bay entrance of the emergency department or the back/staff entrance to the maternal unit.

a. Tour of the facility was conducted with the Chief Nursing Officer (CNO) on 9/09/2013 at approximately 10:25 a.m.

Tour of the emergency department, located at the back of the facility, revealed EMTALA signage was posted in only the waiting room. Entrance, registration, triage, general treatment areas, and the ambulance bay entrance were observed to be without EMTALA signage. The CNO and Director of the Emergency Department confirmed these observations during the tour.

Tour of the maternal (labor & delivery) unit was conducted at approximately 11:20 a.m. on 9/09/2013. EMTALA signage was observed to be located in the small waiting room located prior to entrance of the unit. When in suspected labor, a patient would bypass the emergency department, walk down a long hall, take an elevator up, ring a doorbell, and wait in a small waiting room for staff to arrive and triage/admit her. The EMTALA signage was not located elsewhere on the maternal unit, such as in the treatment areas, hallway, or the back staff entrance, where the emergency department could bring up patients. The CNO and Director of the Maternal (Obstetrics) Unit confirmed these observations during the tour.

On 9/10/2013 at approximately 10:00 a.m., tour of the facility's main entrance was conducted with the CNO. EMTALA signage was located near the main entrance information desk.

Based on review of medical records, facility policy/procedure, and staff interview, the facility failed to ensure two of three (#11 & #14) patients transferred from the facility's emergency department were transferred with appropriate paperwork and documentation of EMTALA specific requirements. This failure did not evidence that appropriate actions were conducted at the time of patient transfer and created the potential for a negative outcome.

Findings:

1. The facility utilized a two page EMTALA Transfer Form and, in review of three medical records of patients transferred from the emergency department to a higher level of care, two of the forms were not completed in entirety and inclusive of critical information.

a. Medical records were reviewed on 9/10/2013.

Sample medical record #11 was a 77 year old male who was referred to the emergency department by an outpatient physician for evaluation of transfer to a higher level of care for a possible procedure on his liver after worsening symptoms. The "Accompanying Documentation" section of the EMTALA Transfer Form was not completed and, therefore, it is unknown if appropriate medical records accompanied the patient's transfer.

Sample medical record #14 was a 35 year old female who was found unconscious on a country road after an apparent motor vehicle accident and alcohol/medication consumption. The patient suffered bleeding within her brain and was in need of immediate neurosurgical evaluation. The EMTALA Transfer Form was without documentation in the following areas: name of destination hospital, name of individual who accepted/received report at the destination hospital (as well as title, phone #, and date/time report called), signature of staff who gave report at transferring hospital, entire portion of accompanying documentation section, entire portion of transportation section (including transport agency, who accompanied patient, and what life support measures required), entire portion of medical orders section (which necessitated if the patient should be on an IV infusion, resuscitated, on a cardiac monitor, NPO, given meds in transfer, or placed on oxygen), and witness signature for the patient consent to transfer, as the patient was unable to consent self. The rest of the patient's medical record was reviewed in attempt to obtain additional data. The physician's emergency department note stated the facility where the patient was transferred for a higher level of care. Additionally, the nurse's final note stated report was called to an "ED RN" at the receiving hospital. However, the record was still not complete with EMTALA information and critical information was not maintained in a clear and concise manner.

b. In an interview with the facility's Chief Nursing Officer, on 9/10/2013 at approximately 1:00 p.m., s/he confirmed that the EMTALA Transfer Form for both patients was not complete.

c. The facility's policy titled "Emergency Medical Treatment & Active Labor," effective 06/03/2013, stated that individuals who have an emergency medical condition not yet stabilized would be transferred upon individual request by signing the transfer request section of the EMTALA Transfer Form. Additionally, it stated a representative of the receiving facility must confirm available space, qualified staff, and agree to accept the transfer. It continued that the facility will send the receiving facility copies of all pertinent available medical records, including seven specific portions as well as "a copy of the completed applicable sections of the EMTALA Transfer Form." The policy also stated the transfer would be accomplished through appropriately trained professionals and transportation equipment. Lack of documentation in the sample medical records did not ensure compliance with this policy or adequate information and record keeping by the facility.

Based on facility policy/procedure, interviews, and medical record review, the facility failed to accept transfer from a referring hospital when it had the capacity to treat the patient and was defined as a higher level of care. This failure created the potential for patient harm.

Findings:

1. The facility maintained a policy which stated all active gastrointestinal hemorrhage (GI Bleeds) requiring therapeutic capabilities that exceed those available at their facility would not be accepted for transfer. The facility's practice, however, was that no GI bleed patient's with elevated LFTs (Liver Function Tests) would be accepted as a transfer from an outside facility, despite not only the underlying cause of the GI Bleed or elevated LFTs but also the extent or severity of the patient's GI Bleed. The facility had gastroenterology physician specialists on staff and on-call as well as capability to treat GI bleeds. The facility could not provide further care should the GI bleed/s progress due to new or baseline liver failure and necessitate a TIPs (Transjugular Intrahepatic Portosystemic Shunt) procedure or transfusion of platelets. These two factors were used as the reason why the facility could not accept a transfer of patients requiring treatment for a GI bleed and, therefore, gastroenterology at the facility may decline acceptance of transfer of GI bleed patients, regardless of their capabilities to treat patients not requiring a TIPS or platelet transfusion.

a. On 7/06/2013, a 54 year old male patient presented at an outside facility due to vomiting blood. (The patient's medical record from the transferring facility was reviewed prior to this complaint investigation on 9/09/2013.) The patient reported vomiting blood since the previous evening and also reported drinking alcohol daily with his last drink days prior. The patient's vital signs were stable, his hematocrit was stable at 47.8 and INR was 1.56. The patient's liver enzymes were mildly elevated: the AST was 120 (normal level is 15 - 46) and ALT was 61 (normal 17 - 61). Per the medical record of the outside hospital, the on-call gastroenterologist at the facility was called by the outside hospital's emergency department physician regarding acceptance of the patient as a transfer to further treatment of his GI bleed, to which the gastroenterologist stated the hospital policy was not to accept alcoholic upper GI bleeds. The patient was transferred to another medical facility for higher level of care and continuation of treatment.

b. The facility's policy titled "Transfers of GI Bleed patients from other hospitals," originally created August, 2000 and last reviewed August, 2010, was reviewed.

The policy stated the following: "Outcome Statement: When patients at other facilities with acute and/or active gastrointestinal (GI) hemorrhage required therapeutic capabilities and/or support services that exceed those available at Mercy Regional Medical Center (MRMC), such patients will not be accepted in transfer by MRMC and should rather be transferred to an institution that can provide all intervention potentially indicated."

The policy continued: "1. MRMC cannot currently provide the full range of interventions and support services indicated for all patients presenting with active and/or acute GI hemorrhage. MRCM has endoscopic capabilities such that non-variceal sources of upper GI hemorrhage can be managed locally within the usual standard of care. However, GI hemorrhage related to portal hypertensive liver disease may exceed local capability. Therefore, MRMC will not accept, from other hospitals, transfer related or likely related to variceal hemorrhage. MRMC medical staff will advise physicians and/or medical centers requesting transfer of such patients to contact a medical center affording all interventions and services potentially required. In most cases, this will be the nearest tertiary care or university medical center."

The policy stated rationale as well as a summary. The summary stated the following: "MRMC will not accept transfer of patients with active and/or acute GI bleeding that is suspected to related to liver disease because: a) MRMC lacks blood band support (particularly platelets) that is often required for the treatment of such GI hemorrhage. b) MRMC lacks salvage procedure capabilities in the event that bleeding is persistent or recurrent despite attempts with first line therapeutic modalities; c) MRMC medical staff cannot reliably predetermine, based on initial testing performed at a referring hospital, the therapeutic requirements, such as salvage procedures and platelet transfusions, for patients with liver-related GI bleeding. d) Patients with GI bleeding who require transfer from one hospital to another should be transferred to facilities capable of providing salvage procedures and immediate platelet transfusions rather than to MRMC which cannot provide either of these services."

c. On 9/09/2013, the facility's emergency room log was reviewed for an emergency room visit and/or admission on 7/06/2013 of a GI bleed patient from an outside facility. There was no record of the patient.

d. Interviews

i. On 9/09/2013 at approximately 1:30 p.m., an interview was conducted with the nurse who worked as the house supervisor on 7/06/2013. S/he stated a specialist physician could have rejected a patient transfer and s/he would have not known about it, as the outside facility is supposed to obtain an accepting physician prior to decision to transfer the patient. S/he continued, "Especially GI. GI is a big problem." The house supervisor stated the Chief Medical Officer had a policy on GI, alcoholism, and accepting patient. S/he stated s/he did not get involved in this matter, but that s/he remembered one past case when an Intensive Care Unit physician accepted a GI Bleed but the gastroenterologist physician declined the transfer. If s/he was called regarding a transfer of this type of patient, the house supervisor stated s/he would refer the decision to the physician.

ii. On 9/09/2013 at approximately 1:40 p.m., the Director of the Emergency Department was asked if s/he was familiar with this policy. S/he state s/he was not and that "we take all patients."

iii. On 9/09/2013 at approximately 1:45 p.m., the Chief Medical Officer was asked about the policy. S/he confirmed the policy was in place and followed. S/he stated if the patient has a history of liver disease, it would better to fly the patient to a facility that could provide full service. S/he stated there was a complaint from an outside facility shortly after initiation of the policy, however, an investigation was never conducted. The Chief Medical Officer was asked how liver disease was defined to which he stated, "It is a bit of a judgment call. That is the call of the gastroenterologist physician. The policy and procedure does not specify." The Chief Medical Officer was asked if FFP (Fresh Frozen Plasma) was supplied at the facility and he confirmed it was. When asked how the facility would treat a patient who presented to the emergency department with a variceal bleed, s/he stated, "If they show up at the door, we treat them. Occasionally, we have to transfer them."

iv. On 9/09/2013 at approximately 2:10 p.m., an interview was conducted with the gastroenterologist physician who was on-call the day of 7/06/2013. The Gastroenterologist (GI MD) confirmed that s/he as on-call during the day of 7/06/2013, however, stated s/he did not recall any conversations or contact with an outside facility. When asked if GI bleeds were treated at the facility, the GI MD stated, "Yes." When asked the usual process for treating GI bleeds, s/he stated, "It depends on the nature of the GI bleed."

The GI MD explained that the policy was created in the late 1990s after a liver cirrhosis patient was treated at the facility but bleeding could not be controlled and, as the event occurred in the winter, it was too dangerous to fly the patient out at the time. The GI MD confirmed that the limitations experienced by the facility for treatment of GI Bleeds and esophageal varicies included inability to perform a TIPS procedure and lack of platelets supply onsite. Although the GI MD did not recall speaking with a physician on 7/06/2013 from an outside facility, s/he reported s/he would have stated what s/he generally states: "I am not accepting or declining this patient. It would be the purview of the hospitalist or Intensivists but if they accept, you should remind them of our policy and procedure." The GI MD stated Emergency Department physicians had argued this policy in the past. The GI MD stated if there were abnormal LFTs for any reason, the policy and procedure would be activated. S/he continued, "It is a red line in the sand. It could be suspected of a portal hypertensive bleed." General treatment for esophageal varicies was reviewed with the GI MD. S/he stated resuscitation, stabilization, intravenous medications (such as Protonix or Octreotide), an urgent upper endoscopy, and blood products (such as FFP) to get the patient's INR less than 1.6 would all be used as needed for treatment. All the stated treatments were available at the facility. The GI MD repeated, "It would have been standard protocol not to have the patient come here."