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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 Active Labor Act (EMTALA) requirements.

Findings:

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

Tag A2406 - Medical Screening Exam - The facility failed to provide an appropriate Medical Screening Exam (MSE) within its capability as required by Emergency Medical Treatment and Active Labor Act (EMTALA) regulations. Specifically, the hospital did not utilize ancillary services routinely available to the emergency department for 4 of 12 patients (Patients #1, #3, #20 and #21) who presented to the off campus emergency department to determine the most appropriate facility for treatment.

Tag A2409 - Appropriate Transfer - The facility failed to ensure patients requiring a higher or specialized level of care were transferred appropriately pursuant to EMTALA (Emergency Medical Treatment and Labor Act) for 1 of 3 psychiatric patients (Patient #3) transferred from the off campus emergency department (ED) to another hospital.

Based on interviews and document review, the facility failed to provide an appropriate Medical Screening Exam (MSE) within its capability as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. Specifically, the hospital did not utilize ancillary services routinely available to the emergency department (ED) for 4 of 12 patients (Patients #1, #3, #20 and #21) who presented to the off campus emergency department to determine the most appropriate facility for treatment.

Findings include:

Facility policies:

The Emergency Medical Conditions: Screening and Treatment policy read, it is the policy of Boulder Community Health to comply with the provisions of the Emergency Medical Treatment and Labor Act (EMTALA), and the regulations promulgated thereunder. Patients who are determined to have an emergency medical condition shall be provided with stabilizing treatment, as required by EMTALA, and shall be transferred or discharged as necessary in accordance with this policy.

Medical screening examination is the process required to reach with reasonable clinical confidence the point at which it can be determined whether or not an emergency medical condition exists. Such screening must be done within the hospital's capabilities and available personnel, including physicians available to the ED and may range from a simple process involving only a brief history and physical (H&P) examination to a complex process that involves performing ancillary studies and procedures.

Transfer: transfer of a patient to another facility is to be considered only when at least one of the following conditions is met: The service required by the patient cannot be provided at the hospital or a transfer to another facility would enhance the medical care benefits offered to the patient because the receiving facility has specialized capabilities or facilities not provided by the hospital or the patient requests a transfer and the facility can provide the service and accepts the patient.

The Emergency Medical Services (EMS) Divert policy read, the hospital may not refuse care. Divert is only used for Trauma and ED. All other capacity issues are considered an Advisory Status. Advisory status is posted when specialty care services are limited or unavailable. Psychiatric advisory is posted when behavioral health care needs exceeds resources and patient safety is at risk. As with divert, when possible patients bypass to another facility with resources. If not possible, patients are transported to the closest facility.

The Admission: Involuntary policy read, a patient on a 72-Hour hold is transferred to another non-BCH facility if BCH does not have the capacity (e.g.., available beds) or capacity (e.g.., appropriate level of care) to treat the patient's medical or mental health condition.

The Behavioral Health Patient Care Guidelines Emergency Department policy read, community medical center ED lacks a safe room and there are no mental health evaluators on site. Patients presenting to the off campus ED falling in the scope above are considered a priority for evaluation and if determined by the ED physician will be transferred to the closest most appropriate facility as soon as possible. At the off campus ED security or staff will provide continuous 1:1 monitoring for immediate intervention for high risk patients until transfer or until the provider has determined no risk exists.

References:

The off campus ED Scope of Services read, the off campus ED will not have psychiatric holding or seclusion rooms. Patients will be transferred to the most appropriate facility for evaluation and definitive care. Staff will provide 1:1 care for patients pending transfer to assure their safety. Services not performed include violent behavioral patient and at risk mental health patients on M1 holds.

The American Medical Response of Colorado (AMR) contract with the facility states urgent requests form the off campus ED will have a response time of 30 minutes or less.

1. The facility failed to utilize resources routinely available for patients who presented to the off campus emergency department to determine the most appropriate facility for transfer rather than closest in proximity.

a. According to Patient #21's History and Physical (H&P), he was seen on 2/3/19 at 9:04 a.m., for agitation. He initially complained of a sore throat and was noted to be physically hyperactive with pressured speech. Patient #21 was released from jail 10 days prior to being seen in the ED and had not been taking his usual psychiatric medications. According to the Emergency Mental Illness Report and Application (M1), Patient #21 was placed on an M1 hold due to agitation, nonsensical and pressured speech, increased physical activity and recently out of jail.

According to the Hospital to Hospital Transfer Document (EMTALA form), Patient #21 was stable and it was medically indicated to transfer him to a higher level of care for a mental health evaluation. Patient #21 was transferred to the closest in proximity facility. Patient #21 was not transferred to the main ED associated with the facility to have a mental health evaluation, which were in the hospitals scope of services, but was instead transferred to another acute care hospital closest in proximity.

Review of the facility's divert log revealed the main ED was not on divert or psychiatric advisory on 2/3/19 when Patient #21 was seen at the off campus ED.

b. According to Patient #1's H&P, she was seen in the off campus provider based ED on 10/18/18 at 11:41 p.m., for an overdose of Prazosin (a medication to treat high blood pressure, but can be used to treat nightmares in patients with post-traumatic stress disorder (PTSD)). Patient #1 was also noted to have taken five tablets of Benadryl the day prior. She had a history of postural tachycardia syndrome (symptoms of lightheadedness, fainting, and rapid heartbeat, when standing up, which were relieved by lying down) as well as long term PTSD with prior suicide attempts. According to the M1 hold, Patient #1 was an imminent danger to herself due to abnormal vital signs with tachycardia (heart rate over 100 beats per minute) and hypertension (high blood pressure) after the overdose of Prazosin 12 milligram (mg).

Review of the EMTALA form revealed it was medically indicated for Patient #1 to transfer from the off campus ED to a higher level of care for observation, intensive care and a psychiatric evaluation. According to the H&P, Physician #4 stated he called the main ED and was told they were on psychiatric divert.

Review of the facility's divert log revealed the main ED was not on divert. The main ED was on a psychiatric advisory from 10/18/18 at 3:37 p.m. to 10/19/18 at 5:33 a.m. and therefore could have accepted patients from an ED within their system.

c. On 4/4/19 at 10:29 a.m., an interview with Physician #4 was conducted. Physician #4 stated the main ED would have been capable of performing the mental health evaluation for Patient #1 then determining placement needs, but he was told they were on psychiatric divert. Physician #4 stated the process to transfer from the off campus ED to the main ED, was for the off campus ED nurse to call the charge nurse or supervisor at the main campus ED to determine if the patient could transfer for a mental health evaluation. Physician #4 stated even though he felt the off campus ED patients were considered patients of the main ED, he did not think they could be transferred to the main ED while it was on psychiatric divert. Physician #4 was informed the main ED was on psychiatric advisory not divert when he transferred Patient #1. Physician #4 stated he had never heard that term prior to the survey. Physician #4 stated he did not know all the psychiatric services which were offered at the separately certified acute care hospital where Patient #1 was transferred to for a mental health evaluation.

d. On 4/4/19 at 7:05 a.m., an interview with the psychiatric clinical intake lead (Lead) #5 was conducted. Lead #5 stated his team evaluated patients to determine if they met criteria for risk to harm themselves, harm others or had a grave disability related to mental health. He stated the mental health evaluation was performed once the patient was medically cleared by the physician. Lead #5 stated patients which walked into the main ED while it was on divert or psychiatric advisory were still evaluated and not turned away. Lead #5 stated his team had conversations with the police and ambulance transport services in which they were still permitted to bring patients to the main ED if they were on psychiatric advisory.

Lead #5 stated patients seen at the off campus ED did not receive mental health evaluations by his team due to staffing. Lead #5 stated the off campus ED patients were not considered patients of the main ED until they arrived to the main ED. He stated off campus ED patients could be diverted if the main ED was on advisory status. Lead #5 stated the charge nurse at the main ED made the determination if a patient was permitted to transfer from the off campus ED.

e. According to Patient #3's H&P, she went to the off campus ED on 2/6/19 at 12:17 a.m., after an overdose of 900 mg of Benadryl (a medication used as a sedative because it causes drowsiness) and had drank alcohol. Patient #3 was placed on a mental health hold (M1) due to intentional self-harm.

Review of the EMTALA form revealed Patient #3 was transferred to a separately certified acute care hospital for a psychiatric evaluation and admission for a level of care or service not available at the off campus ED. According to the EMTALA form, Patient #3 was stable for transfer.

f. On 4/3/19 at 8:00 a.m., an interview with Physician #6 was conducted. Physician #6 stated if an off campus ED patient was stable, they would be transferred to the main ED for a mental health evaluation. Physician #6 stated transportation times did have an impact on his decision where to send a patient that needed a higher level of care. Physician #6 stated when he called AMR to transport a patient non-emergently to the main ED, it could take an hour for them to arrive. Alternatively, he stated when he called 911 the transport team who responded would arrive to take the patient to the closest acute care facility within five minutes. This was in contrast to the AMR contract which stated response to the off campus ED would be 30 minutes. When asked why Patient #3 did not go to the main ED non-emergently, Physician #6 explained he felt Patient #3 was unstable to wait one hour for transport. Physician #6 stated he had not fully documented his thought process to explain why he felt Patient #3 was unstable since the EMTALA form revealed she was stable.

g. According to the H&P, Patient #20 was seen by Physician #7 on 3/2/19 at 3:13 p.m. Patient #20 went to the off campus ED with complaints of vomiting and diarrhea for several hours. Patient #20 had a sodium level of 117 and was diagnosed with hyponatremia (low sodium). Her sodium level was rechecked after receiving intravenous (IV) fluid and had decreased to 112. Physician #7 documented in his ED note hypertonic saline was not available at the off campus ED and 911 was called to transfer patient to the nearest ED. There was no documented evidence Physician #7 called the main ED to ask if they had the solution Patient #20 needed.

h. On 4/3/19 at 7:25 a.m., an interview with Physician #8 was conducted. Physician #8 stated the amount of time for transportation to arrive to the off campus ED was a factor used to determine where a patient would be transferred to for further treatment. Physician #8 stated if a patient could wait in the ED for two hours without being a detriment to themselves or others then he would call AMR for transportation to the main ED for additional treatment unable to be provided by the off campus ED. Physician #8 stated if a patient could not wait for two hours, he would call 911. Physician #8 stated the ambulance team would transport the patient to the facility closest in proximity to the hospital.

i. On 4/4/19 at 8:50 a.m., an interview with the associate vice president of nursing (VP) #1 was conducted. VP #1 stated a review of Patient #3's medical record was conducted by herself and the medical director. VP #1 stated they did not review the record to determine if Patient #3 had an appropriate transfer. VP #1 stated they trusted the doctor's decision to send patients when they transferred a patient to a higher level of care. Additionally, VP #1 stated the off campus ED had difficulties transferring patients to a higher level of care based on their ability to transport. VP #1 stated they struggled with AMR because the transport service did not want to leave their patrol area to transfer patients from the off campus ED to the main ED. VP #1 stated the transportation team which responded to 911 calls would only transport patients to the closest in proximity ED. VP #1 stated the facility had a lot of work to do to figure out a solution to the transportation issue.

Based on interviews and record review, the facility failed to ensure patients which required a higher or specialized level of care were transferred appropriately pursuant to EMTALA (Emergency Medical Treatment and Labor Act) for 1 of 3 psychiatric patients (Patient #3) transferred from the off campus emergency department (ED) to another hospital.

Findings include:

Facility policies:

The Emergency Medical Conditions: Screening and Treatment policy read, it is the policy of Boulder Community Health to comply with the provisions of the Emergency Medical Treatment and Labor Act (EMTALA), and the regulations promulgated thereunder. Patients who are determined to have an emergency medical condition shall be provided with stabilizing treatment, as required by EMTALA, and shall be transferred or discharged as necessary in accordance with this policy.

The Transfers: Another Acute Care Facility read, the purpose was to ensure that any patient, regardless of age, requiring transfer to another acute care facility is transferred in a safe manner and with sufficient documentation. Transfers will comply with state and federal regulations. The transferring nurse is responsible for providing a nurse to nurse report and assuring pertinent medical records (as defined on the EMTALA form) accompany the patient.

The Transportation Plan: CMC ED policy read, EMTALA paperwork is required for all transfers to other facilities. This includes acceptance by facility and medical provider, level of care for transfer, consent for transfer, report and handoff.

1. The facility failed to send the completed EMTALA form with Patient #3 when she was transferred from the off campus ED to an acute care facility for a higher level of care.

a. According to Patient #3's History and Physical (H&P) she went to the off campus ED on 2/6/19 at 12:17 a.m., after an overdose of 900 milligrams (mg) of Benadryl (a medication used as a sedative because it causes drowsiness) and drank alcohol. Patient #3 was placed on a mental health hold (M1) due to intentional self-harm.

Review of the Hospital to Hospital Transfer Document (EMTALA form) revealed Patient #3 was transferred to an acute care facility for a psychiatric evaluation and admission. Further review of the EMTALA form showed the following documents were sent with Patient #3: provider reports, electronic health record (EHR) transfer report which included lab results and medications administered, medication reconciliation report, imaging files, electrocardiogram (( EKG) a test that records the electrical activity of your heart), M1, advance directives and a copy of the EMTALA form.

Review of Patient #3's medical record revealed Registered Nurse (RN) #2 did not send the EMTALA form with Patient #3 when she was transferred from the off campus ED to an acute care facility by emergency transport. RN #2 documented a note on 2/12/19 at 7:07 a.m., which stated she faxed the EMTALA form to the acute care hospital. The note was written by RN #2 six days after Patient #3 was transferred from the off campus ED to an acute care facility. The process of faxing the EMTALA form was in contrast to the policy which stated the EMTALA form should be sent with the patient upon transfer.

b. On 4/2/19 at 3:05 p.m., an interview with RN #2 was conducted. RN #2 stated when a patient was transferred from the off campus ED to another facility, she would send the EMTALA form along with any pertinent patient history or medical information with the patient. RN #2 stated she sent those forms for continuity of care to help the receiving facility care for the patient. RN#2 stated if the patient was sent from the off campus ED emergently and she did not have enough time to fill out the EMTALA form prior to the patient transfer, she would fax the EMTALA form to the receiving facility after the patient left the facility. RN #2 confirmed she did not send the EMTALA form with Patient #3 when she was transferred. RN #2 stated the reason was because the ambulance arrived to transfer Patient #3 to the acute care facility before she had enough time to fill out the EMTALA form. Additionally, RN #2 stated she also did not call a nurse to nurse report to the receiving facility until after the patient had left the off campus ED as well due to time constraints.

c. Review of RN #2's Unit Competencies revealed on 7/12/16 she was trained on the transfer process which required sending the completed EMTALA form with a patient which was transferred from the off campus ED to an acute care facility. RN #2 was also trained on the mental health policies.

d. On 4/3/19 at 12:19 p.m., an interview with RN #3 was conducted. RN #3 was identified as the clinical team lead. RN #3 stated the process to transfer a patient from the off campus ED to an acute care facility was for the RN to call a report to the receiving RN after the physician ensured there was a receiving physician. RN #3 stated she would then call for transport and create a packet for all the paperwork that was going to be sent with the patient while she waited for transport to arrive. The transfer packet would include the EMTALA form. RN #3 stated once the patient was on the gurney for transport, she would give the transport team the paperwork packet to go with the patient.

e. On 4/4/19 an interview with Associate Vice President of Nursing (VP) #1 was conducted. VP #1 stated after review of Patient #3's medical record and EMTALA review, the EMTALA form was not sent with Patient #3 during transport.