HospitalInspections.org

Based on record review and interview, the hospital staff failed to implement the Emergency Medical Treatment and Labor Act (EMTALA) and related policies and procedures (P&P) when the hospital failed to ensure:

1. Physician certification forms were complete for six (6) of 14 sampled patients (Patients 101, 102, 103, 104, 205, and 207).
2. Physician certification form time closely matched the transfer time for six (6) of 14 sampled patients
(Patients 102, 206, 207, 208, 209 and 210).
3. Patients' vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) were documented at transfer for seven (7) of 14 sampled patients (Patients 101, 102, 205, 206, 207, 209, and 210).
4. The against medical advice (AMA) form was complete for one (1) of 14 sampled patients (Patient 204).

The failures placed patients at risk of not being aware of their rights upon transfer, potentially not being declared stable at time of transfer, as evidence of not having any vital signs documented at time of transfer which could result in patient's condition decompensating while in route to another facility.

Findings:

1.During a review of the hospital's policy and procedure (P&P) titled, "Emergency Medical Treatment and Labor Act (EMTALA)," dated 11/28/23, PROCEDURE part (5) (f) indicated, "A physician must sign an express written certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risk to the individual or ... from being transferred. The certification should meet the following requirements: i. The certification must state the reason for transfer ... But should be specific to the condition of the patient upon transfer. ii. The certification must contain a complete picture of the benefits to be expected from appropriate care at the receiving facility and the risk associated with that transfer ..."

a) During a review of Patient 101's medical record, the medical record indicated, Patient 101 presented to the emergency department (ED) on 11/2/23 with complaint of facial pain after a fall. A trauma surgeon was contacted at another hospital who recommended to transfer patient to their hospital for surgical treatment for mandible open fracture (broken jaw). Patient 101's "EMTALA Certification and Transfer Form," was reviewed and indicated, the form was not complete. Review of Patient 101's "Patient Consent/Request for Transfer," indicated, the date and time area was blank, there was no physician signature, and the date and time after the physician signature area was also blank. Patient 101 was transferred to another hospital on 11/2/23 at 12:38 p.m.

b) During a review of Patient 102's medical record, the record indicated, Patient 102 presented to the ED on 11/5/23 with complaint of altered mental status. Patient 102 was found to be hypothermic with a temperature of 86.1 Fahrenheit degrees (normal is 98.6) requiring intensive care unit setting for monitoring and further work-up. Patient 102's " EMTALA Certification and Transfer Form," was reviewed and indicated, the form was not complete. The Mode/Support During Transfer as Determined by Physician area was left blank, there was no indication of the type of equipment or personnel required for transfer. The Consent to Transfer to another facility was left blank, there was no indication to which facility and for what purpose Patient 102 was being transferred. Review of Patient 102's Unable to Obtain Written Consent box was checked, there was no reason for not consenting patient to transfer documented. The Reason area was left blank. Patient was transferred to another hospital on 11/5/23 at 4:05 p.m.

c) During a review of Patient 103's medical record, the record indicated, Patient 103 presented to the ED on 11/8/23 with complaint of abdominal pain. Review of physician note, dated 11/8/23, indicated, labs and imaging were notable for pancreatitis (pancreas infection), biliary dilation, possible occluded common bile duct (CBD) stent, requiring gastroenterologist consultation and treatment at another hospital. Patient 103's "EMTALA Certification and Transfer Form," was reviewed and indicated, the form was not complete. The Physician's signature date, and time were missing, area was left blank, no indication the date and time the form was signed. Patient was transferred to another hospital on 11/9/23 at 3:53 a.m.

d) During a review of Patient 104's medical record, the record indicated, Patient 104 presented to the ED on 11/18/23 with complaint of abdominal pain. Review of physician note indicated, abdominal pain has improved though not resolved after analgesics. Patient requires transferring to another hospital for surgical consult for chronic or recurrent early appendicitis (infection of the appendix). Patient 104's "EMTALA Certification and Transfer Form," was reviewed and indicated, the form was not complete. The Consent to Transfer to another facility area was left blank, no indication for what purpose the patient was being transferred. The Physician's signature, date, and time were missing, the area was left blank. Patient 104 was transferred to another hospital on 11/18/23 at 9:29 p.m., by private automobile.

e) During a review of Patient 205's medical record, the record indicated, Patient 205 presented to the ED on 11/22/23 with complaint of abdominal pain. According to physician's note concern for possible preterm labor (when a patient goes into labor before 36 weeks). As no ultrasound available at our facility, labor and delivery patient requires transfer to labor and delivery facility. Patient 205's " EMTALA Certification and Transfer Form," was reviewed and indicated, the Reason for Transfer box was not checked. The Mode/Support During Transfer as Determined by Physician area was blank; there was no indication of the type of equipment and personnel required for transfer. The Physician's printed name, signature, date, and time were missing. Patient 205 was transferred to another hospital on 11/22/23 at 1:50 a.m.

f) During a review of Patient 207's medical record, the record indicated, Patient 207 presented to the ED on 12/2/23 with complaint of cough and difficulty breathing. According to physician's note labs and imaging reviewed, impression epiglottitis (swelling of the small movable part in the throat). Transfer for ENT consult. Patient 207's "EMTALA Certification and Transfer Form," was reviewed and indicated, the form was not complete, the Condition/diagnosis was missing. Patient 207 was transferred to another hospital on 12/2/23 at 9:15 a.m.

During a concurrent review of the EMTALA Certification and Transfer form and interview with the ED medical director (EDMD) on 12/20/23 at 9:45 a.m. the EDMD confirmed that if any area on the form was left blank then the form was not complete.

2. During a review of the hospital policy and procedure (P&P) titled, "Emergency Medical Treatment and Labor Act (EMTALA)," dated 11/28/23, PROCEDURE part (5) (f) indicated "A physician must sign an express written certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risk to the individual or ... from being transferred. The certification should meet the following requirements: iii. The date and time of the physician certification should closely match the date and time of the transfer."

a) During a review of Patient 102's medical record, the record indicated, Patient 102 presented to the ED on 11/5/23 with complaint of altered mental status. Patient 102 was found to be hypothermic with temperature of 86.1 Fahrenheit degrees (normal is 98.6) requiring intensive care unit setting for monitoring and further work-up. Patient 102's "EMTALA Certification and Transfer form," was reviewed and indicated, the physician signed, dated, and timed the form on 11/5/23 at 12:47 p.m. The patient was transferred to another hospital on 11/5/23 at 4:05 p.m. The time between when the form was signed and the time the patient left the hospital ED was 3 hours and 18 minutes.

b) During a review of Patient 206's medical record, the record indicated Patient 206 presented to the emergency department (ED) on 11/20/23 with complaint of swelling. Impression: Hypoxemia (a low level of oxygen in the blood). Patient 206's "EMTALA Certification and Transfer Form," was reviewed and indicated, the physician signed, dated, and timed the form on 11/20/23 at 3 p.m. The patient was transferred to another hospital on 11/20/23 at 4:25 p.m. The time between when the form was signed and the time the patient left the hospital ED was 1 hour and 25 minutes.

c) A review of Patient 207's medical record was conducted on 12/19/23. Patient presented to the emergency department (ED) on 12/2/23 with complaint of cough and difficulty breathing. According to physician's note labs and imaging reviewed, impression epiglottitis (swelling of the small movable part in the throat). Transfer for ENT consult. Patient 207's "EMTALA Certification and Transfer Form," was reviewed and indicated, physician signed, dated, and timed the form on 12/2/23 at 6:30 a.m. The patient was transferred to another hospital on 12/2/23 at 9:15 a.m. The time between when the form was signed and the time the patient left the hospital ED was 2 hours and 45 minutes.

d) During a review of Patient 208's medical record, the record indicated, Patient 208 presented to the emergency department (ED) on 11/29/23 with complaint of chest pain. According to physician's note labs and imaging reviewed, impression chest pain and angina pectoris. Transfer for telemetry and cardiology. Patient 208's "EMTALA Certification and Transfer Form," was reviewed and indicated, physician signed, dated, and timed the form on 11/29/23 at 11:35 a.m. The patient was transferred to another hospital on 11/29/23 at 1:45 p.m. The time between when the form was signed and the time the patient left the hospital ED was 2 hours and 10 minutes.

e) During a review of Patient 209's medical record, the record indicated Patient 209 presented to the emergency department (ED) on 11/23/23 with complaint of generalized weakness. According to physician's note labs and imaging reviewed, impression diabetic ketoacidosis (DKU) (a serious condition caused by not enough insulin in the body). Transfer for DKU evaluation and ICU admission. Patient 209's "EMTALA Certification and Transfer Form," was reviewed and indicated, physician signed, dated, and timed the form on 11/23/23 at 3:55 p.m. The patient was transferred to another hospital on 11/23/23 at 5:00 p.m. The time between when the form was signed and the time the patient left the hospital ED was 1 hour and 5 minutes.

f) During a review of Patient 210's medical record, the record indicated, Patient 210 presented to the emergency department (ED) on 11/27/23 with complaint of abdominal pain. According to physician's note labs and imaging reviewed, impression aortic dissection, abdominal (tear or damage to the inner wall of the aorta). Transfer for telemetry and consult for aortic dissection. Patient 210's "EMTALA Certification and Transfer Form," was reviewed and indicated, physician signed, dated, and timed the form on 11/27/23 at 2:55 p.m. The patient was transferred to another hospital on 11/27/23 at 8:44 p.m. The time between when the form was signed and the time the patient left the hospital ED was 5 hours and 49 minutes.

During a concurrent interview and record on 12/20/23 at 9:35 a.m. with the ED medical director (EDMD), the "EMTALA Certification and Transfer form," was reviewed. The EDMD was asked how much time was consider "closely" to match the time of the transfer. Initially, the EDMD indicated the physician certification transfer form should be completed at the time of transfer. Then started explaining the form is completed when patient is accepted at another hospital. The timeframe varies from patient to patient. It was shared with EDMD the language "closely" in the policy is left open for interpretation therefore the hospital needs to define what timeframe is considered "closely."

3. During a review of the hospital's policy and procedure (P&P) titled, "Emergency Medical Treatment and Labor Act (EMTALA)," dated 11/28/23, PROCEDURE part (1) (c) indicated, "Continuous Monitoring: The medical secreening examination MSE is a continuous process reflecting ongoing monitoring in accordance with an individual's needs. Monitoring will continue until the individual is stabilized or appropriately transferred. Reevaluation of the individual must occur prior to discharge or transfer."

a) During a review of Patient 101's medical record, the record indicated, Patient 101 presented to the emergency department (ED) on 11/2/23 with complaint of facial pain after a fall. Patient 101's vital signs were only performed on 11/2/23 at 11:42 a.m. Patient 101 was transferred to another hospital at 12:38 p.m., without any vital signs performed at the time of transfer.

b) During a review of Patient 102's medical record, the record indicated Patient 102 presented to the ED on 11/5/23 with complaint of altered mental status. Patient was found to be hypothermic with temperature of 86.1 Fahrenheit degrees (normal is 98.6) requiring intensive care unit setting for monitoring and further work-up. The last vital signs performed for Patient 102 was on 11/5/23 at 12:13 p.m., the patient's temperature was still low at 88.6 Fahrenheit degrees. Patient was transferred to another hospital on 11/5/23 at 4:05 p.m., without any vital signs performed at the time of transfer.

c) During a review of Patient 205's medical record, the record indicated, Patient 205 presented to the ED on 11/22/23 with complaint of abdominal pain. Patient 205's vital signs were only performed on 11/22/23 at 1:10 a.m. Patient was transferred to another hospital at 1:50 a.m., without any vital signs performed at the time of transfer.

d) During a review of Patient 206's medical record, the record indicated, Patient 206 presented to the emergency department (ED) on 11/20/23 with complaint of swelling (all over his body). Patient 206's last vital signs were performed on 11/20/23 at 3:30 p.m. Patient was transferred to another hospital at 4:25 p.m., without any vital signs performed at the time of transfer.

e) During a review of Patient 207's medical record, the record indicated, Patient 207 presented to the emergency department (ED) on 12/2/23 with complaint of cough and difficulty breathing. Patient 207's last vital signs were performed on 12/2/23 at 8:35 a.m. Patient was transferred to another hospital at 9:15 a.m., without any vital signs performed at the time of transfer.

f) During a review of Patient 209's medical record, the record indicated Patient 209 presented to the emergency department (ED) on 11/23/23 with complaint of generalized weakness. Patient 209's last vital signs were performed on 11/23/23 at 4:37 p.m. Patient was transferred to another hospital at 5 p.m., without any vital signs performed at the time of transfer.

g) During a review of Patient 210's medical record, the record indicated, Patient 210 presented to the emergency department (ED) on 11/27/23 with complaint of abdominal pain. Patient 210's last vital signs were performed on 11/27/23 at 7:26 p.m. Patient was transferred to another hospital at 8:44 p.m., without any vital signs performed at the time of transfer.

During an interview on 12/20/23 at 9:53 a.m., with the ED Medical Director (EDMD), the EDMD indicated the ED staff performed vital signs on patients at time of transfer in accordance with standard practice.

During an interview on 12/19/23 at 10:01 a.m. with the ED Director (EDD), the EDD indicated usually their practice was to perform vital signs on patients 15-30 minutes prior to discharge or transfer.

4. A review of the hospital policy and procedure (P&P) titled "Leaving Hospital Against Medical Advice (AMA)", dated 9/27/22, the P&P indicated, PROCEDURE: "The physician must attempt to provide the patient ... information regarding why continued hospitalization is recommended ... the potential consequences of the action (the risks involved in leaving) ... DOCUMENTATION: Completion of the AMA form and ensure that it is on the medical record."."

During a concurrent interview and record review on 12/20/23 at 9:05 a.m. with ED medical director (EDMD), Patient 204's "Leaving Hospital Against Medical Advice (AMA)," dated 11/17/23 was reviewed. The AMA indicated, there were no date, time, physician's printed name, or Physician's signature documented for when and who explained the risks of leaving AMA. EDMD stated the AMA form should be complete and this one is not.