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Based on observation, interviews, review of documentation in 9 of 9 medical records of patients who were transferred from the ED to another hospital (Patients 7, 8, 9, 10, 11, 20, 21, 22 and 23), review of central log documentation, and review of hospital policies and procedures and other documents, it was determined that the hospital failed to develop and enforce EMTALA policies and procedures in the following areas:
* Physician on-call responsibilities;
* Appropriate transfers of patients;
* Maintenance of a central ED log;
* Required posting of EMTALA signs; and
* Whistleblower protection.

Findings included:

1. Physician On-call Responsibilities: Refer to the findings identified under Tag A2404, CFR 489.20(r)(2) and (j)(1-2), which reflects the hospital's failure to enforce its EMTALA policies and procedures related to physician on-call responsibilities.

2. Appropriate Transfers: Refer to the findings identified under Tag A2409, CFR 489.24(e)(1-2), which reflects the hospital's failure to enforce its EMTALA policies and procedures related to appropriate transfers.

3. Central Log: Refer to the findings identified under Tag A2405, CFR 489.20(r)(3), which reflects the hospital's failure to develop and enforce EMTALA policies and procedures related to maintenance of the required Central Log.

4. Posting of Signs: Refer to the findings identified under Tag A2402, CFR 489.20(q)(1-2), which reflects the hospital's failure to develop and enforce EMTALA policies and procedures related to posting of the required EMTALA signs.

5. Hospital EMTALA policies and procedures were reviewed and contained no reference to the required EMTALA whistleblower protection.

During an interview with the Quality Management Coordinator on 04/26/2016 at 1645, he/she confirmed the hospital had no policies and procedures that addressed the required EMTALA whistleblower protection.

Based on observation, interviews, and review of policies and procedures it was determined the hospital failed to ensure that EMTALA signage was posted conspicuously in places and areas that could be seen by all individuals presenting to the hospital for emergency services, including examination and treatment areas. In addition, EMTALA signage in Spanish language was not posted and visible for all Spanish-speaking individuals who presented to the hospital for emergency services.

Findings include:

1. A tour of the ED was conducted on 04/25/2016 beginning at 1600 with the Quality Management Coordinator and the ED Manager. Staff present during the tour indicated that the department had one primary ambulatory entrance and one separate ambulance entrance, 58 treatment rooms and 4 seclusion rooms.

Observations during the tour revealed that there was one EMTALA sign posted at the ambulance entrance to the ED. However, that EMTALA sign was written in English only, and not in Spanish. For Spanish-speaking individuals who presented to the hospital by ambulance for emergency services, the required EMTALA signage was not visible for all individuals. In addition, there was no EMTALA signage observed posted during observation of treatment rooms 1, 2, 4, and 42; and EMTALA signage was partially occluded by equipment and/or supplies and was not fully visible during observation of treatment rooms 28, 43 and 44. These observations were confirmed with staff present during the ED tour.

During an interview with the ED Manager at the time of the ED tour on 04/25/2016, he/she confirmed that all Spanish-speaking individuals who presented to the hospital by ambulance did not have the opportunity to visualize EMTALA signage that was intended for Spanish-speaking individuals.

2. A tour of the L&D department was conducted on 04/25/2016 beginning at 1645 with the Quality Management Coordinator and the ED Manager. Staff present during the tour confirmed that women in labor primarily presented directly to the L&D department. The tour included but was not limited to observations made of the patient and visitor waiting area, registration area, and a triage room. No EMTALA signage was observed during the tour.

During interviews with the L&D Charge Nurse and the Nurse Educator during the tour on 04/25/2016, the L&D Charge Nurse and Nurse Educator indicated that they did not know of any signs that were posted in the department.

3. Hospital EMTALA policies and procedures were reviewed and contained no reference to the required posting of EMTALA signs.

4. During an interview with the Quality Management Coordinator on 04/26/2016 at 1200, he/she confirmed the hospital had no policies and procedures that addressed the required posting of EMTALA signs.

Based on interview and review of documentation in 1 of 4 ED records of patients who presented to the ED with lower extremity pain and who were transferred to another facility (Patient 22), and review of hospital policies and procedures and other documents, it was determined that the on-call specialty physician failed to come in to the hospital at the request of the ED physician to provide examination and/or treatment necessary to stabilize the patient's emergency medical condition.

Findings include:

1. The Professional Staff Policies and Procedures dated as last revised 08/23/2015 was reviewed. "Article XVII. Additional Policies...Section 5. Emergency Call" required that "...All Active and Active Provisional Physician Members of the Professional Staff who hold core privileges in their specialty areas are required to take emergency call. Such call shall include emergency situations within the Emergency Department...Members must be available to respond by phone, and when clinically indicated in person, to the Hospital(s) within thirty (30) minutes when on the published emergency call schedule. For purposes of this policy, the ED physician shall make the determination of whether it is clinically indicated that the on call physician responds to a request in person in the Emergency Department."

2. The ED record for Patient 22 was reviewed. The "ED Arrival Information" reflected the patient presented to the ED by ambulance on 04/05/2016 at 2048. The patient's chief complaint was foot numbness and calf pain and the patient's acuity was recorded "Urgent."

ED Provider Notes electronically signed by the ED physician (Physician A) and dated 04/05/2016 at 2129 reflected "Patient arrives...with symptoms of critical limb ischemia with a pulseless, painful, numb, cool leg. This likely relates to known PVD...Patient was medicated for pain and a heparin drip was immediately ordered. Concerned for critical limb ischemia, I attempted to call the on-call [cardiologist], as this is the physician who had most recently seen this patient for [his/her] PVD. I spoke with [a physician], on-call for this team, who felt that the patient likely needs surgical intervention that [he/she] would be unable to provide and that I needed to speak with a vascular surgeon. I then spoke to...our on-call vascular surgeon. [He/she] stated that [he/she] would not see this patient until the patient was seen by the patient's cardiology team...Ultimately, it appeared that the most expeditious way to get the patient care was to transfer to [PPMC]...Patient with persistent symptoms on recheck...Transferred to PPMC via ALS ambulance..."

ED Provider Notes electronically signed by another ED physician (Physician B) and dated 04/05/2016 at 2216 reflected "The patient was seen in conjunction with [Physician A above]...In brief [Patient 22] is a [male/female] with chronic peripheral vascular disease aortic aneurysmal disease who has undergone several procedures for these problems...Unfortunately today the patient had sudden onset of severe pain in [his/her] right leg and now arrives with an obviously cold ischemic leg. [Physician A] promptly identified the situation and brought it to my attention and we initiated evaluation and treatment for this patient...We then proceeded to contact appropriate physician to care for this patient. We initially spoke to [vascular physician] who requested that we call the patient's cardiologist...[He/she] also requested that we speak to [two other physicians]...We have now finally arranged for this patient to be transported via ALS to [PPMC]..."

An untitled transfer form dated dated 04/05/2016 was reviewed. The document was electronically signed by the "transfering (sic) Provider" on 04/05/2016 at 2200. The form reflected the following:
* "Patients's condition has not been stabilized..."
* "Reason for Transfer: Services Unavailable."
* "Summary of Transfer Benefits: PCP has privileges only at transferring facility."

The document reflected the patient was transferred to PPMC by ambulance on 04/05/2016. The "Time of Transfer" was reflected as "2306 --- 04/05/2016 2304."

An RN note dated 04/06/2016 at 0008 reflected the patient was discharged.

3. The untitled physician's on-call schedule for April 2016 was reviewed. The schedule reflected that the vascular physician, who was called by Physicians A and B for Patient 22, was scheduled as on-call for the ED on 04/05/2016 from 8:00 AM to 11:59 PM and 04/06/2016 from 12:00 AM to 8:00 AM.

4. An interview was conducted on 04/25/2016 at 1205 with the Director of Quality Management. The Director stated that the hospital had initiated an investigation related to the incident involving Patient 22. The Director stated that Patient 22 presented to the ED on 04/05/2016 by ambulance with foot numbness and calf pain and was provided a MSE by Physician A. The Director stated that after conducting the MSE, Physician A determined the patient needed vascular services in order to further evaluate and treat the patient's condition. The Director stated that Physician A called the on-call vascular physician. The Director stated that the on-call vascular physician did not come to the hospital to further evaluate and treat the patient and he/she instead told Physician A to contact a physician group. The Director stated that the patient was then transferred to another hospital for vascular services. The Director stated that the hospital violated physician on-call requirements because it did not ensure that the vascular physician, who was on-call for the hospital, came in to evaluate and treat Patient 22, resulting in the patient's transfer to another hospital.

5. An interview was conducted on 04/26/2016 at 1100 with the ED physician, Physician B. He/she stated that on 04/05/2016 Patient 22 presented to the ED with a cool, pale, pulseless and painful leg. Physician B stated that Physician A, who was another ED physician, evaluated the patient and determined that the patient needed vascular services. Physician B stated that Physician A then discussed the patient's condition with him/her. Physician B stated that after he/she saw the patient, he/she agreed that the patient needed vascular services. Physician B stated "We knew the diagnosis pretty quickly. It was pretty straight forward. We needed to find someone to fix the problem." Physician B stated that Physician A placed a call to the vascular physician who was on call, and the vascular physician told him/her to call a cardiologist. Physician B stated he/she then placed another call to the vascular physician and described the patient's condition to him/her. Physician B stated that the vascular physician told him/her "[Patient 22] has doctors who've seen him/her before and they need to take care of their patient." Physician B acknowledged that the vascular physician refused to come to the ED and evaluate the patient. Physician B also acknowledged that the patient was transferred to PPMC for vascular services that could have been provided at the hospital if the vascular physician had come to the hospital and treated the patient.

6. An interview was conducted on 04/26/2016 at 1255 with the Director of Quality Management. The Director stated he/she spoke with the vascular physician "last night" (on 04/25/2016) regarding the 04/05/2016 incident involving Patient 22. The Director stated that the vascular physician acknowledged he/she was on-call for vascular services when Patient 22 presented to the hospital on 04/05/2016. The Director stated that the vascular physician acknowledged that Physician A called him/her because Patient 22 needed vascular services but did not come to the hospital to evaluate the patient because he/she didn't think the patient was critical and because he/she thought the patient should be seen by a physician the patient had seen before. The Director stated there was a delay in the patient's treatment because the patient had to be transferred to another hospital for vascular services. The Director stated "As far as EMTALA is concerned, [vascular physician] was responsible for the patient. He/she took accountability."

7. An interview was conducted on 04/27/2016 at 1200 with the Quality Management Coordinator. He/she stated the hospital had no evidence that reflected the vascular physician had received EMTALA training.

Based on interview, review of ED central log documentation for April 2015 through April 2016, and review of policies and procedures, it was determined the hospital failed to develop and enforce its EMTALA policies and procedures to ensure maintenance of a central log which contained complete information about patients who presented to the hospital for emergency services and their disposition.

Findings included:

1. The hospital's ED log for the period of April 2015 through April 2016 was reviewed. The log was electronically generated and contained nine columns of patient information entered including the following: Medical record numbers, facility, patient name, age, arrival date/time, chief complaint, ED discharge disposition and arrival method.

The log contained omissions that included but were no limited to the following
* The entry on the log for Patient 27 was reviewed and reflected the patient's arrival date was 04/05/2016 at 1448. However, the ED discharge disposition column was not completed and was blank.
* The entry on the log for Patient 28 was reviewed and reflected the patient's arrival date was 04/05/2016 at 2229. However, the ED discharge disposition column was not completed and was blank.
* The entry on the log for Patient 29 was reviewed and reflected the patient's arrival date was 04/19/2016 at 2021. However, the ED discharge disposition column was not completed and was blank.
* The entry on the log for Patient 30 was reviewed and reflected the patient's arrival date was 04/21/2016 at 2007. However, the ED discharge disposition column was not completed and was blank.
* The entry on the log for Patient 31 was reviewed and reflected the patient's arrival date was 04/21/2016 at 2233. However, the ED discharge disposition column was not completed and was blank.
* The entry on the log for Patient 32 was reviewed and reflected the patient's arrival date was 12/04/2015 at 2001. However, the chief complaint was not completed and was blank.
* The entry on the log for Patient 33 was reviewed and reflected the patient's arrival date was 10/25/2015 at 0330. The chief complaint was not completed and was blank.

2. Hospital EMTALA policies and procedures were reviewed and contained no reference to the required central ED log.

3. During an interview with the Quality Management Coordinator on 04/26/2016 at 1200, he/she confirmed the hospital had no EMTALA policies and procedures that addressed the required central ED log.

Based on interview, documentation reviewed in 9 of 9 medical records of patients who presented to the hospital's ED and who were transferred to other facilities (Patients 7, 8, 9, 10, 11, 20, 21, 22 and 23), and review of hospital policies and procedures, it was determined that the hospital failed to effect all aspects of an appropriate transfer of those individuals as required by the hospital's policies and procedures. The hospital failed to ensure the required physician certification that the benefits of the transfer outweighed the increased risks of transfer. Patient specific risks of transfer were not identified for those patients.

Findings include:

1. Review of the hospital's policy titled "Emergency Treatment and Active Labor Act (EMTALA) Patient Transfers Between Facilities," dated last revised "03/2016" reflected the following: "This policy applies to all patient populations, including pediatrics, presenting to an Emergency Department with an emergency medical condition needing transfer to or from a Providence hospital." The procedure section of the policy reflected: "...Prior to transfer, an explanation of the need to transfer and the alternative to transfer will be made to the patient. Risks and benefits will be summarized verbally and documented on the Patient Transfer Form...Documentation to occur on patient's chart..."

2. The ED record for Patient 22 was reviewed. The record reflected the patient presented to the ED by ambulance on 04/05/2016 at 2048. The chief complaint was foot numbness and calf pain. The acuity was recorded as "Urgent."

The "ED Provider Notes" electronically signed by the physician and dated 04/05/2016 at 2129 reflected "Patient arrives...with symptoms of critical limb ischemia with a pulseless, painful, numb, cool leg...Patient with persistent symptoms on recheck...Transferred to [PPMC] via ALS ambulance...Critical lower limb ischemia."

An untitled transfer form dated 04/05/2016" was reviewed. The "Provider Documentation" section dated 04/05/2016 at 2200 reflected the following:
* "Patient's Condition: Patient's condition has not been stabilized..."
* "Comments: All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport. There is also potential for worsening of medical condition during transport resulting in possible disability and/or death."
* "Summary of Transfer Risks: Risks and benefits of transfer for this individual have been considered, and no other risks beyond those listed above are anticipated." The form was electronically signed by the "transfering (sic) Provider" and dated 04/05/2016 at 2200.

The form reflected the patient was transferred to another hospital by ALS on 04/05/2016 and the "Time of Transfer" was recorded "2306 --- 04/05/2016 2304."

There was no documentation to reflect that the physician had identified patient specific transfer risks, and certified that the benefits of the transfer outweighed patient specific risks.

3. The ED record for Patient 20 was reviewed. The record reflected the patient presented to the ED by wheelchair on 11/15/2015 at 1301. The chief complaint was chest pain. The acuity was recorded as "Urgent."

The "ED Provider Notes" electronically signed by the physician and dated 11/15/2015 at 1334 reflected "...In the past 12 hours...the patient has experienced recurrent bouts of chest pain requiring frequent doses of nitroglycerin...I also think further risk stratification should be entertained given [his/her] risk for recurrent coronary disease ... I reviewed this case with [physician]...at [another hospital] and they have asked that we transfer this patient...for ongoing evaluation and further treatment."

An untitled transfer form dated 11/15/2015" was reviewed. The "Provider Documentation" section dated as recorded "11/15/2015 1624" reflected the following generic language:
* "Comments: All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport. There is also potential for worsening of medical condition during transport resulting in possible disability and/or death."
* "Summary of Transfer Risks: Risks and benefits of transfer for this individual have been considered, and no other risks beyond those listed above are anticipated." The form was electronically signed by the "transfering (sic) Provider" and dated 11/15/2015 at 1624.

The date and time of transfer was not recorded on the form. The "Nurse Signature" space was blank.

The bottom portion of the form reflected "I acknowledge that my medical condition has been evaluated and explained to me. It is the opinion of the physician responsible for my care that the benefits of transfer outweigh the risks of transfer, and I consent to be transferred for further care. The "Patient Signature" and "Date & Time" spaces were blank.

The "Patient Care Timeline" recorded by the RN on 11/15/2015 at 1749 reflected the patient was discharged.

There was no documentation to reflect that the physician had identified patient specific transfer risks, and certified that the benefits of the transfer outweighed patient specific risks.

4. The ED record for Patient 10 was reviewed. The record reflected the patient presented to the ED by wheelchair on 12/20/2015 at 1539. The chief complaint was shortness of breath, fall, back pain and leg pain. The acuity was recorded as "Emergent."

The "ED Provider Notes" electronically signed by the physician and dated 12/20/2015 at 1559 reflected "...[patient] presents with headache, neck pain, back pain, right anterior chest wall pain and left leg pain after falling 10 feet to the ground from a ladder and landing on [his/her] back...[He/she] was transferred to the ED...[He/she] did have tenderness at [his/her] C-spine, T-spine and L-spine...The patient complained of moderate right anterior chest wall tenderness...[He/she] had a puncture wound at [his/her] left lower anterior tibia with moderate surrounding soft tissue tenderness...Given the patient's presentation, [he/she] will need to be transferred to the trauma center...ALS was contacted and will provide a code 3 transport..."

An untitled transfer form dated 12/20/2015 was reviewed. The "Provider Documentation" section dated as recorded "12/20/2015 1638" reflected the following:
* "Summary of Transfer Benefits: Higher level of service available at receiving facility."
* "Comments: All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport. There is also potential for worsening of medical condition during transport resulting in possible disability and/or death."
* "Summary of Transfer Risks: Risks and benefits of transfer for this individual have been considered, and no other risks beyond those listed above are anticipated." The form was electronically signed by the "transfering (sic) Provider" and dated 12/20/2015 at 1638.

The form reflected the patient was transferred to another hospital by ALS on 12/20/2015 and the "Time of Transfer" was recorded "1638 --- 12/20/2015 1635."

The form reflected it was signed by the nurse on 12/20/2015 at 1646, which was after the time of the patient transfer. The patient's signature on the form was not dated and timed.

There was no documentation to reflect that the physician had identified patient specific transfer risks, and certified that the benefits of the transfer outweighed patient specific risks.

5. The ED record for Patient 7 was reviewed. The record reflected the patient presented to the ED by ambulance on 12/17/2015 at 2204. The chief complaint was severe abdominal pain. The acuity was recorded as "Emergent."

The "ED Provider Notes" electronically signed by the physician and dated 12/18/2015 at 0126 reflected "...[Patient] presents with acute onset of right lower quadrant pain with nausea, vomiting and diarrhea...Patient continued to be in extreme pain here...At this point with inability to control [his/her] pain we felt that transfer to [another hospital]...was warranted..."

An untitled patient transfer form dated 12/17/2015 was reviewed. The "Provider Documentation" section dated as recorded "12/18/2015 0241" reflected the following generic language:
* "Comments: All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport. There is also potential for worsening of medical condition during transport resulting in possible disability and/or death."
* "Summary of Transfer Risks: Risks and benefits of transfer for this individual have been considered, and no other risks beyond those listed above are anticipated." The form was electronically signed by the "transfering (sic) Provider" and dated 12/18/2015 at 0241.

The "Nurse Signature" space on the form was blank.

The bottom portion of the form reflected "I acknowledge that my medical condition has been evaluated and explained to me. It is the opinion of the physician responsible for my care that the benefits of transfer outweigh the risks of transfer, and I consent to be transferred for further care." The "Patient Signature" and "Date & Time" spaces were blank.

There was no documentation to reflect that the physician had identified patient specific transfer risks, and certified that the benefits of the transfer outweighed patient specific risks.

6. The ED record for Patient 9 was reviewed. The record reflected the patient presented to the ED by "Walk-in" on 12/20/2015 at 1527. The chief complaint was "Laceration."

The "ED Provider Notes" electronically signed by the physician and dated 12/20/2015 at 1931 reflected "...[Patient] comes in after falling on a knife which cause (sic) a laceration in the supra region...[patient] had a potential to deteriorate. We spoke to [another hospital] and they're willing to accept [him/her] as a trauma transfer."

An untitled transfer form dated 12/20/2015 was reviewed. The "Provider Documentation" section reflected the following generic language:
* "Comments: All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport. There is also potential for worsening of medical condition during transport resulting in possible disability and/or death."
* "Summary of Transfer Risks: Risks and benefits of transfer for this individual have been considered, and no other risks beyond those listed above are anticipated." The form was electronically signed by the "transfering (sic) Provider" and dated 12/20/2015 at 1934.

Documentation on the form reflected the patient was transferred to another hospital by ALS on 12/20/2015 and the "Time of Transfer" was recorded "2005 --- 12/20/2015 2004."

The form reflected the patient signed the form on 12/20/2015 at 2010 after he/she was transferred.

There was no documentation to reflect that the physician had identified patient specific transfer risks, and certified that the benefits of the transfer outweighed patient specific risks.

7. Similar findings were identified during the review of the records for Patients 8, 11, 21 and 23.










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