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Based on a review of facility documentation and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to provide an appropriate Medical Screening Examination within the capability of the hospital's emergency department for one of 20 medical records reviewed (MR1).

Findings include:


Review on August 9, 2021, at approximatley 1:30 PM, of "Emergency Medical Treatment and Labor act (EMTALA)" last reviewed by the facility on September 2015, revealed, "... It is the policy of the hospitals of Heritage Valley Health System (HVHS) to require all emergency transfers within the system, or out of the system to follow the requirements of the Emergency Medical treatment and Labor Act (EMTALA). ... Emergency medical conditions will be carefully screened, stabilized, and treated regardless of ability to pay or any other form of discrimination. ... An individual will be considered to have come to the Emergency Department (ED) if he/she is on hospital property or is in an ambulance on hospital property. ..."

Review on August 5, 2021, at approximatley 3:30 PM of documentation provided by the facility revealed that MR1 presented to the hospital via ambulance. The patient was brought into the emergency department on May 17, 2021, at 14:57, but the EMS staff person decided to transfer the patient to another hospital for trauma, prior to the patient having a medical screening. The facility staff indicated that the EMS staff member removed the patient from the facility. The EMS staff member indicated that when he/she asked if the patient should be taken to another hospital, the facility staff [name unknown] stated "yes".

Review of MR1 on August 5, 2021, at approximatley 3:40 PM revealed "...EMS Assessment Interventions. ... EMS decided to transfer pt ... [patient to MR1] was found to have unequal pupil response and EMS medic decided to take the patient to a more appropriate facility ..."

Continued review of MR1 on August 5, 2021, at approximatley 3:45 PM revealed a ED addendum note dated May 17, 2021, and timed 15:25, which indicated, 'When the patient was registered, ... [MD] was in the dictation room and [MD] signed up for the patient. Shortly thereafter, ... [MD] came out to see the patient and the patient was going. The nurse said that medics had decided to take the patient to [an outside facility], because they were concerned about blown pupils. [MD] was not aware of any of this decision making until the patient had already left the Department. [MD] was never able to evaluate the patient. ..."

During an interview on August 2, 2021, at approximatley 9:50 AM EMP2 confirmed that the facility failed to provide an appropriate medical screening examination for MR1.

Based on a review of facility documents, Medical Records (MR), and staff interviews (EMP), it was determined that the facility failed to appropriately transfer a patient to another facility for one of one transfers reviewed, and the facility failed to have a transfer consent completed for seven of 11 transfers.(MR1, MR2 MR3, MR4 MR5, MR 7 and MR8). In addition the facility failed to document that the transferring medical records were sent to the receiving facility for 8 of 11 medical records. (MR1, MR2 MR3, MR4, MR6, MR7, MR8, MR18).


Findings include:

Review on August 9, 2021, at approximatley 1:30 PM, of "Emergency Medical Treatment and Labor act (EMTALA)" last reviewed by the facility on September 2015, revealed, "... It is the policy of the hospitals of Heritage Valley Health System (HVHS) to require all emergency transfers within the system, or out of the system to follow the requirements of the Emergency Medical treatment and Labor Act (EMTALA). ... Emergency medical conditions will be carefully screened, stabilized, and treated regardless of ability to pay or any other form of discrimination. ... An individual will be considered to have come to the Emergency Department (ED) if he/she is on hospital property or is in an ambulance on hospital property. ... When an unstable individual requires transfer, the hospital must provide treatment to minimize the risk of the transfer. The physician must certify the need of the transfer, and make a reasonable effort to obtain the informed consent or refusal to transfer. ..."

Review on August 9, 2021, at approximatley 3:30 PM of MR1 revealed that the receiving facility was not notified of the patient transfer, and there was no consent for the transfer for MR1.

Review on August 9, 2021, at approximatley 12:45 PM revealed that MR2 presented to the facility on July 31, 2021, at 22:28 AM and was transferred to an outside facility on August 1, 2021 at 08:20. Continued review of MR2 revealed that there was no transfer consent completed. The medical record for MR2 did not include documentation that the medical record was sent to the receiving facility.

Review on August 9, 2021, at approximatley 12:50 PM revealed that MR3 presented to the facility on March 26, 2021, at 11:46 AM, and was transferred to an outside facility on March 26, 2021, at 22:20. Continued review of MR3 revealed that there was no transfer consent completed. The medical record for MR3 did not include documentation that the medical record was sent to the receiving facility.

Review on August 9, 2021, at approximatley 12:55 PM revealed that MR4 presented to the facility on March 25, 2021, at 17:10, and was transferred to an outside facility on March 25, 2021, at 22:01. Continued review of MR4 revealed that there was no transfer consent completed. The medical record for MR4 did not include documentation that the medical record was sent to the receiving facility.

Review on August 9, 2021, at approximatley 12:55 PM revealed that MR5 presented to the facility on June 18, 2021, at 14:10 and was transferred to an outside facility on the same day at 19:15. Continued review of MR5 revealed that the transfer consent was not completed.

Review on August 9, 2021, at approximatley 12:58 PM revealed that MR6 presented to the facility on March 4, 2021, at 03:07 and was transferred to an outside facility on March 5, 2021, at 08:00. The medical record for MR6 did not include documentation that the medical record was sent to the receiving facility.

Review on August 9, 2021, at approximatley 1:00 PM revealed that MR7 presented to the facility on March 5, 2021, at 10:54, and was transferred to an outside facility on the same day at 16:26.. Continued review of MR7 revealed that there was no transfer consent completed. The medical record for MR7 did not include documentation that the medical record was sent to the receiving facility.

Review on August 9, 2021, at approximatley 1:00 PM revealed that MR8 presented to the facility on April 23, 2021, at 19:08 and was transferred to an outside facility on the same day at 21:33. Continued review of MR8 revealed that there was no transfer consent completed. The medical record for MR8 did not include documentation that the medical record was sent to the receiving facility.

Review on August 9, 2021, at approximatley 12:40 PM revealed that MR18 presented to the facility on July 9, 2021, at 15:41 and was transferred to an outside facility on July 9, 2021, at 21:30. The medical record for MR18 did not include documentation that the medical record was sent to the receiving facility.

During an interview conducted on August 9, 2021, at approximatley 12:50 PM EMP2 confirmed that the transfer records above did not include the completed consents and confirmed that the transferred records did not include documentation that the medical records were sent to the receiving facility.