HospitalInspections.org

Based on observations, interviews, documentation reviewed in 11 of 11 medical records of patients who presented with an emergency medical condition (EMC) and who were transferred to other facilities (#s 3, 16, 17, 18, 19, 20, 23, 24, 25, 26, and 27), review of policies and procedures, and review of police report documentation it was determined that the hospital failed to enforce its EMTALA policies and procedures related to patient transfer and the required posting of signs.

Findings include:

1. Refer to the findings identified under Tag A2409, CFR 489.24 (e)(1)-(2), Appropriate Transfer, which reflects the hospital's failure to effect appropriate transfers for patients who presented to the emergency department (ED) with an EMC in accordance with its policies and procedures.

Interview with the DNS (Director of Nursing Services) on 11/18/2011 at approximately 1330 revealed the medical center was aware many policies and procedures had not been reviewed and revised. The DNS stated that after the previous quality resources manager left the position, it was discovered that many policies and procedures had not been reviewed as expected.

The "EMTALA (Screening Stabilization and Transfer of Patients with Emergency medical conditions)" Policy and Procedure was last approved August 10, 2006.

2. Refer to the findings identified under Tag A2402, CFR 489.20(q), Posting of Signs, which reflects the hospital's failure to post the required EMTALA signs in accordance with its policies and procedures.

Based on observation, interviews, and review of policies and procedures, it was determined that the hospital failed to post the required EMTALA signs in accordance with its own policies and procedures.

Findings include:

1. A tour of the ED was conducted on 11/16/2011 at 1100 with the Director of Emergency Services. The tour began at the patient walk-in entrance to the department where patients and visitors are met by registration staff. From this viewpoint, signage specifying the EMTALA rights of individuals was not visible. The waiting room had two separate seating areas and the signage in English and Spanish was visible only in the second waiting area. The signage was not visible from the first waiting area. The Director of Emergency Services stated that the signage had been placed in a more visible spot until approximately 6-8 months earlier. The tour continued through the ambulance entrance of the ED past the central nursing station and into various patient rooms and bays. There was no signage in the main emergency department or patient treatment rooms.

2. A tour to confirm the posting of the signage specifying the rights of individuals with emergency medical conditions and women in labor was conducted on the Women's Health and Birth Center on 11/18/2011 at 1045 with the Chief Quality Officer (CQO). No signage was observed at that time.

Later that morning after the tour, the CQO reported the sign had recently fallen and had not been replaced until after the lack of signage was brought to their attention.

3. The McKenzie-Willamette Medical Center Policy #AM04-011, "EMTALA (Screening Stabilization and Transfer of Patients with Emergency medical conditions)," last approved August 10, 2006 was reviewed. Page 20 reflected the following internal requirement: "Signage...The hospital will post conspicuously signs that specify the rights of individuals under the law with respect to examination and treatment for emergency medical conditions and of women who are pregnant and are having contractions. These signs will be posted in the Emergency Department and Women's Health and Birth Center and other areas of the hospital where patients may wait prior to examination and treatment for emergency medical conditions."

Based on interviews, documentation reviewed in 11 of 11 medical records of patients who presented with an EMC and who were transferred to other facilities for stabilizing treatment (Patient #s 3, 16, 17, 18, 19, 20, 23, 24, 25, 26, and 27), and the review of police report documentation it was determined that the hospital failed to effect appropriate transfers of those patients. The hospital failed to ensure that the other hospital the patient was transferred to had accepted the patient in all cases; the hospital failed to ensure the required physician certification that the benefits of transfer outweighed the risks of transfer in all cases; and the hospital failed to ensure that appropriate records were transferred with the patient in all cases.

Findings include:

1. McKenzie-Willamette Medical Center (Hospital #1) does not have an inpatient behavioral health unit. Hospital #2 is approximately five miles from Hospital #1, in the city adjacent to the city in which Hospital #1 is located. Hospital #2 operates a 36-bed inpatient behavioral health unit which is the only hospital inpatient behavioral health unit within a 50 to 70 mile geographic area.

2. The medical record for Patient #3 who presented to the Hospital #1's ED was reviewed. The record reflected that Patient #3 walked into the hospital's ED accompanied by [a family member] on 11/09/2011 at 0335. The chief complaint was multiple lacerations.

The physician's ED report was dictated on 11/09/2011 at 0633 and transcribed on 11/09/2011 at 0758. The Chief Complaint was "Laceration." The Final Diagnoses were listed as "1. Self-mutilation. 2. Psychotic outburst. 3. Harm to Self. 4. Refusal of psychiatric care and transport by Springfield police to a psychiatric holding facility." Under the heading "Presenting Illness," the report reflected "This...[male/female] presented to the [ED] stating that he awoke from sleep with violent images from [his/her] time in Iraq, and in order to get the images out of [his/her] head, [he/she] said [he/she] was hitting [him/herself] in the head and face repeatedly. This did not work, and then [he/she] slashed both of [his/her] forearms in an attempt to take the image and pain of [his/her] experiences away...[He/she] has had previous attempts of suicide..." Under the heading "Emergency Department Course Summary, Diagnostics, and Treatment" the report reflected "[He/she] had wounds cleansed and irrigated...The patient was then noted thereafter to have removed [his/her] Steri-Strips and asked for new Steri-Strips. The patient, while in the [ED], was noted to have stolen a trauma sheers from the nursing station and stealthily brought them to [his/her] bedside...At that time, [he/she] was moved from [his/her] bed to the secure room...[He/she] was noted to have at some point then stolen a prescription pad...When advised to the patient that I am very much concerned with [his/her] emotional, seemingly psychotic, outbursts for the traumatic flashback images...that [he/she] should have a psychiatric evaluation, [he/she] stated that there was no [derogatory term] way that [he/she] would have it done, [he/she] would not go to [Hospital #2 Behavioral Health Unit]...I stated that [he/she] would need to be taken away by police in handcuffs...I then did make a call to the police department in Springfield who insisted that a holding form be initiated, and I am at this time waiting for the Springfield police to pick up the patient to be taken to a more secure facility..."

The addendum to the physician's ED report was dictated on 11/09/2011 at 0722 and transcribed on 11/09/2011 at 1019. Review of the record reflected "The police arrived on-scene in the [ED] and were going to to take the patient to [Hospital #2] emergency facility, and I did call [Hospital #2] and did speak with [Physician #2]. I tried to give [him/her] a heads-up as to the situation that was present in the [ED] here, giving [Physician #2] a full background on what had transpired with the patient. The patient is an involuntary patient with definitive harm and risk to [him/herself], that [he/she] was being taken by police under police custody to their facility...this is a psychiatric patient who has demonstrated violent outbursts, has cut both of [his/her] forearms, had demonstrated harm to self...The patient was clearly unsafe. [He/she] had threatened to leave, that the police were escorting the patient to [Hospital #2]..."

The record reflected that the patient was transported by the police from the hospital on 11/09/2011 at 0657. Although the documentation reflected that the physician had called a physician at Hospital #2, there was no documentation that reflected that the physician at Hospital #2 had accepted the patient.

There was no transfer form, or other documentation in the record that reflected that another hospital had accepted the patient for transfer or that the physician had signed a certification that the benefits of the transfer outweighed the risks of transfer.

3. The MWMC ED physician, Physician #1, who treated Patient #3 on 11/09/2011 was interviewed on 11/18/2011 at 0925. The physician was provided a copy of Patient #3's medical record for review and was asked to describe what happened during the patient's ED visit on 11/09/2011. The physician stated "My dictated report is my most accurate picture." The physician said the patient presented to the ED with self inflicted arm lacerations. The physician reported "Those in themselves were not an emergency medical condition" and "The presiding issue was a difficult psych issue."

The physician listed the reasons the police were called to escort the patient from the ED. He/she said the patient had an "uncontrolled event, traumatic flashbacks with self inflicted injuries," the patient had refused care; the patient had "made the threat of 'you better call police and they better bring guns;" and the physician reported "it had gotten to a point where I was concerned for [his/her] safety." The physician was asked if he/she had considered ordering a medication for the treatment of the behavioral symptoms the physician had described. The physician reported that the patient "maintained enough that [he/she] was not acting violently and as long as there were no violent outbursts it might be best for [him/her] to be in [his/her] normal frame of mind so the other health care providers would get a true sense of [his/her] psychiatric symptoms." This was inconsistent with the physician's addendum to the ED report dictated on 11/09/2011 at 0722 which reflected "...this is a psychiatric patient who has demonstrated violent outbursts, has cut both of [his/her] forearms, had demonstrated harm to self..." and the physician's statement during this interview that the patient had "made the threat of 'you better call police and they better bring guns."

The physician said there was no crisis worker coverage for hospital patients at night after 2200 or 2400 midnight. The physician said that if crisis worker coverage had been available, he/she would have "absolutely considered this as an intervention" for Patient #3.

The physician revealed that he/she contacted the ED physician at Hospital #2 and informed him/her that the patient was being escorted by police to that hospital. The physician said he/she never asked the physician at Hospital #2 whether or not the hospital had the capacity to care for the patient and further stated "I never felt I was transferring [him/her]."
He/she reported that the patient was being treated as leaving the hospital against medical advice (AMA). However, he/she confirmed that no AMA paperwork had been reviewed with the patient nor had AMA documentation been completed.

During the interview, the physician revealed that he/she was part of a contracted physician group; he/she was "generally" familiar with EMTALA requirements; he/she had not received any EMTALA training from MWMC; and the last EMTALA training he/she had received was more than 3 years ago.

4. The Hospital #2 ED physician, Physician #2, who treated Patient #3 was interviewed on 11/17/2011 at 1630. Physician #2 reported that he/she received a phone call from MWMC's ED, Physician #1 on 11/09/2011 at "a little before" 0700. Physician #1 said he/she was "sending a patient to you." Physician #1 said he/she had called [Hospital #2's Behavioral Health Unit] and a Veterans Administration Medical Center (VAMC) and "they had no beds." Physician #2 further revealed that Physician #1 sounded panicked and said "I can't keep [him/her] here." Physician #2 said he/she offered to assist Physician #1 by checking [Hospital #2 Behavioral Health Unit] bed availability him/herself, and stated "I made it very clear [to Physician #1] that if there were no beds [in Hospital #2's Behavioral Health Unit] I could not accept the patient." Physician #2 said he/she called [Hospital #2's Behavioral Health Unit] and Physician #4, a Psychiatric physician for Hospital #2, and verified there were no beds available in [Hospital #2's Behavioral Health Unit]. Physician #2 said he/she called Physician #1 back within 7-9 minutes of the first phone conversation. Physician #2 told Physician #1 that he/she had spoken to staff at [Hospital #2's Behavioral Health Unit] and said "we have no beds and I can't accept the patient." Physician #2 told Physician #1 that it would be an EMTALA violation if he/she sent the patient. Physician #2 further reported that Patient #3 arrived at Hospital #2 with the police "a few minutes" after the second phone conversation ended. Physician #2 stated "I never accepted the patient." Additionally, Physician #2 said Patient #3 arrived with "no EMTALA transfer form."

5. A report titled "Incident/Custody Springfield Police Department" was received by facsimile on 11/23/2011 at 1018 from a Springfield Police Department Records Clerk. The report was completed by a Springfield Police Department Officer. The report was reviewed and reflected "Occurred Date" 11/09/2011 at 0546 and "Date and Time Prepared" 11/10/2011 at 0730. The report reflected "On the listed date and time I was dispatched to a report of a [male/female] that had been put on a physician's hold at [Hospital #1]. It was reported that the [male/female] had cut [him/herself] on the forearms prior to coming to the hospital. It was further reported that the [male/female] had taken a pair of scissors while at the hospital and threatened to cut [him/herself]. When told that police were coming to the hospital the [male/female] told hospital staff that 'they better bring guns'...[Physician #1] provided me with physician hold paperwork...[Patient #3] was placed in handcuffs that were double locked...[Patient #3] was transported to [Hospital #2] for evaluation..."

6. An interview was conducted with Hospital #2's Risk Manager on 11/17/2011 at 1730. The Risk Manager presented a packet of medical records and said the packet was all of the documentation that had been received by Hospital #2 from MWMC for Patient #3 on 11/09/2011. The records were reviewed and included page one of a two-page physician's report dated as printed on 11/09/2011 at 0600 and labeled "Draft" from MWMC. Additional records received by Hospital #2 from MWMC were a partially completed document with the heading "To The Circuit Court of the State of Oregon For Lane County [Patient #3] an alleged mentally ill person, whose date of birth is [Patient #3's date of birth]. Notice of Mental Illness Emergency Hospitalization by a Physician" dated 11/09/2011 and signed by Physician #1 at 0600; one page of a "Draft" medical record for Patient #31, which was a list of diagnoses and treatments, dated 11/09/2011; four pages of lab results for Patient #3 which were all labeled "Not Part of the Medical Record," and 38 pages of medical records dated 4/19/2010 through 11/08/2011 from a VAMC.

Those records were compared with Patient #3's record from MWMC. The "Draft" physician's report dated as printed on 11/09/2011 at 0600 which was received by Hospital #2 from MWMC was not contained in Patient #3's medical record at MWMC.

Patient #3's record from MWMC included the following documentation which was not in the packet presented by Hospital #2's Risk Manager on 11/17/2011 at 1730: Six nurse's Assessments and Reassessments which included two Suicide Lethality Assessments. The following are examples: A nurse's Adult Assessment on 11/09/2011 at 0612, reflected "Overall Suicide Lethality Score...Suicide Risk High...; and a nurse's Reassessment on 11/09/2011 at 0521, reflected "...[Patient] being very loud asking for things to hurt [him/herself]..."

The documentation further lacked a 4-page ED physician's report transcribed on 11/09/2011 at 0758 from MWMC, and a 2-page addendum to the ED physician's report transcribed on 11/09/2011 at 1019 from MWMC. The documentation lacked physician orders dated 11/09/2011 which included lab work, medications, and treatments for the patient's forearm wounds from MWMC.

Additionally, there was no transfer form, or other documentation in the record that reflected the physician had signed a certification that the benefits of the transfer outweighed the risks of transfer.

7. Medical record #16: The nurse's Initial Assessment Form reflected that Patient #16 walked in to the ED accompanied by a friend on 05/16/2011 at 1449. The physician's ED report dictated on 05/16/2011 at 1659 and transcribed on 05/17/2011 at 0134 reflected "Time Seen: 1517 hours...Chief Complaint...Vaginal bleeding. The record revealed the patient was 17 1/2 weeks pregnant..." and reflected "Today, at about 45 minutes ago, [he/she] bent over to sit back up, but had a large gush of clear fluid and bloody fluid. [He/she] had about 6-8 minutes cramping as well...Pelvic: Exam reveals an opened cervical os. There is some very thin blood, looks like it is mixed with clear fluid. In the vaginal vault, there is some membrane which is coming through the os at this time...Medical Decision Making: I spoke with...the obstetrician on-call. [He/she] would like the patient transferred over to [Hospital #3] in case there are still actual fetal heart tones, they attempt cerclage to keep this pregnancy going. I suspect that this is more likely a late miscarriage and [blank line] to assist [him/her] through that process with the age of the baby, so the patient is being transferred by ambulance to [Hospital #3].

The hospital transferred the patient with a diagnosis of "Threatened abortion" by ground Emergency Medical Services to Hospital #3 on 05/16/2011 at 1710. There was no transfer form, or other documentation in the record that reflected the physician had signed a certification that the benefits of the transfer outweighed the risks of transfer.

8. Medical record #23: The nurse's Initial Assessment Form reflected that Patient #23 walked in to the ED on 05/16/2011 at 1652 accompanied by "self." The physician's ED report dictated 09/23/2011 at 1903 and transcribed on 09/23/2011 at 2022 reflected "...presents to the [emergency room], sent down actually from the wound care center...as [he/she] just does not feel like living anymore. [He/she] said [he/she] has been suicidal in the past, I guess...held a shotgun to [his/her] head and thought about killing [him/herself]. Now, [he/she] wants to overdose on [his/her] narcotic analgesics...Psychological...[He/she] does seem depressed and I do think [he/she] warrants an evaluation...We got the crisis Social Work evaluation down here, spent a great deal of time with [him/her]...Impression: Acute exacerbation of chronic depression with suicidal ideation..."

The nurse's disposition on 09/23/2011 at 2236 reflected "Transfer: Other special needs include secure transport...Transferred to [Hospital #2]...Patient left the department at 09/23/2011 23:11." There was no transfer form, or other documentation in the record that reflected the physician had signed a certification that the benefits of the transfer outweighed the risks of transfer.

9. Interview with the Director of Emergency Services on 11/17/2011 at 1200 included a review of Record #s 16 and 23. He/she confirmed that both records had no transfer form and said they "looked like transfers" to him/her. He/she further said that transfer forms should have been completed for those records.

10. The records of Patient #s 17, 18, 19, 20, 24, 25, 26, and 27, who were transferred to other facilities, each contained a form titled "Transfer Form", form number 03706-TR-501, dated as revised 09/20/2007, which contained spaces for all the components of an appropriate transfer. The Transfer Form identified generic risks of transfer rather than specific risks associated with the patient's specific condition. It identified four generic risks as: "All transfers involve some risk including, but not limited to: deterioration of condition, unforeseen problems such as mechanical failure, accidents and/or lack of specialized equipment or personnel en route." There were no patient specific and individualized risks associated with transfer identified in any of these cases on the Transfer Form or elsewhere in the record.

11. An interview was conducted with the Director of Emergency Services on 11/17/2011 at 1200. He/she was aware that there were a lack of specific risks identified on transfer forms for patients who were transferred from the hospital to other facilities. The Director said he/she didn't even bother to check for this when he/she completed audits of ED medical records because "its such a problem." He/she said the usual practice was for the nurse to complete the benefits section of the form and the physician to complete the risks section, and then the physician signed the form. He/she said the problem was that physicians did not consistently complete the risks section of the form. He/she further identified that the form itself was part of the problem because the risks and benefits were listed after the physician signature section on the form.

12. The records of Patient #s 17 and 23 lacked documentation which reflected that the patient's medical records were sent with the patient at the time of transfer.


29709