HospitalInspections.org

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Based on record review and interview during the Federal Survey, it was determined that the facility failed to assess and analyze Emergency Department (ED) patient transfers, and patients who left AMA (Against Medical Advice), to identify opportunities for improvement.

Findings:

Review of the Transfer Out Log (patients transferred from the facility's ED to other facilities) between 01/2013 and 12/2013 revealed that the following numbers of patients were transferred to other facilities in 2013:

Twenty (20) - January
Twenty (20) - February
Fifteen (15) - March
Twenty-Five (25) - April
Twenty-Six (26) - May
Sixteen (16) - June
Twenty-Two (22) - July
Twenty-Five (25) - August
Nineteen (19) - September
Twenty-Six (26) - October
Seventeen (17) - November
Twelve (12) - December

Review of the AMA Log between 01/2013 and 11/2013 revealed that the following numbers of patients signed out AMA in 2013 during this time period:

Twenty (20) - January
Seventeen (17) - February
Seventeen (17) - March
Seventeen (17) - April
Twelve (12) - May
Eleven (11) - June
Twelve (12) - July
Twenty-Three (23) - August
Sixteen (16) - September
Seventeen (17) - October
Twenty-Three (23) - November

During an interview with Staff #4 on 02/14/14 at 1:45PM, Staff #4 stated that the numbers for ED patients transferred to other facilities, and for patients who leave AMA, are collected monthly. The numbers are forwarded to the Chairman of the Department who submits them to the Health System Data Base. Staff #4 agreed there was no documented evidence that the transfer and AMA numbers were assessed and analyzed to identify opportunities for improvement.
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Based on observation and staff interviews during the Federal Survey, it was determined that the facility failed to post EMTALA (Emergency Medical Treatment & Active Labor Act) signage. Specifically, EMTALA signs were not posted in the Pediatric Waiting Room of the Emergency Department (ED) and the Labor and Delivery Department.

Findings:

During a tour of the Emergency Department on 02/12/14 at 9:45AM it was observed that EMTALA signage in English and Spanish was posted in the Main Waiting Room.

There was no EMTALA signage posted in the Pediatric Waiting Room as well as the Pediatric Triage Area.

During interview with Staff #2 on 02/12/14 at 11:45AM, Staff #2 stated that it was an oversight that the EMTALA signage was not posted in the Pediatric Waiting Room and Triage Area.

During a tour of the Labor and Delivery (L/D) Unit on 02/13/14 at 11:45AM, there was also no signage in areas where a pregnant patient would present requesting emergency care and evaluation.

During an interview conducted on 02/13/14 at 12:00PM with Staff #3, Staff #3 stated that some patients, instead of going to the ED for emergent care or OB (Obstetric) issues, would go straight to the L/D Unit. Staff #3 also confirmed that there was no EMTALA signage.
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Based on Medical Record review, facility policy, and staff interviews during the Federal Survey, it was determined the facility failed to secure written informed refusal of treatment for patients opting to leave the Emergency Department (ED) prior to the completion of stabilization treatment for an emergency medical condition. This was evident in one (1) of three (3) records reviewed for patients leaving the hospital Against Medical Advice (AMA) in a total sample of thirty (30) Medical Records (Patient #1).

Findings:

Review of the ED Triage Form dated 10/14/13 at 8:06PM documented that Patient #1 was brought to the ED by ambulance with a chief complaint of laceration to the back of head secondary to a fall. The patient had a past medical history of Hypertension. The ED Triage Form also documented that the patient refused to be evaluated and treated and was leaving AMA.

During review of Patient #1's Medical Record on 02/13/14, the Medical Record lacked evidence that the patient had completed the AMA Forms as required by the facility's policy. The record also lacked documentation indicating that the patient, or patient's representative, had refused to sign the form.

During interview with Staff #1 on 02/14/14 at 11:45AM, Staff #1 stated that they were unable to find the signed AMA Form. Staff #1 stated that the Physician did sign the patient out AMA but could not locate the form in the patient's Medical Record. Additionally, Staff #1 was unable to locate documented evidence in the record that the patient had refused to sign the AMA Form.

The facility's Policy and Procedure titled "Leaving Against Medical Advice (AMA)" dated 04/19/12 was reviewed on 02/14/14. Section (e) under Patients with Capacity documented all reasonable steps will be taken to have the patient complete the "Release When Patient Leaves Hospital Facility Against Medical Advice" Section of the Consent to Admission and Treatment Form (Attachment A), and Section (f) documents in the event the patient refuses to sign this form, the refusal should be documented in the Medical Record.