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Based on interview and record review, the hospital failed to document the type of ambulance used to transfer 1 of 20 sampled patients (Patient 10). The hospital also failed to maintain a policy specifying that it would report suspected inappropriate transfers in. The deficient practices eliminated accountability regarding whether the ambulance used to transport Patient 10 was appropriate for his needs, and eliminated a policy provision demanded by federal regulations in order to encourage investigation of concerns regarding suspected patient dumping.

Findings:

1. Refer to A-2409 regarding lack of documentation regarding the type of ambulance used to transfer Patient 10.

2. Review of the hospital's policy number "7010 EMTALA" (Emergency Medical Treatment and Labor Act), "EMTALA GUIDELINES FOR EMERGENCY DEPARTMENT SERVICES", revised 10/2020, indicated the policy did not address reporting of suspected inappropriate transfers to the hospital. Review of the hospital's policy number 20.40, "PATIENT ADMISSION and TRANSFER POLICY", revised 10/2020 indicated the policy also did not address reporting of suspected inappropriate transfers in to the hospital.

In an interview on 12/11/20 at 1:19 p.m., the Director of Acute Services (DAS) stated the hospital did receive transfers from other hospitals. In an interview on 12/14/20 at 8:18 a.m., the Chief Nursing Officer (CNO) stated she was unable to locate a policy addressing reporting of inappropriate transfers in.

Review of an e-mail from the Compliance Officer to the surveyor dated 12/15/20 (after conclusion of the survey) indicated the DAS had located a policy addressing reporting of suspected inappropriate transfers in to the hospital. The policy attached to the e-mail did address the topic, but was a prior version of policy number "7010 - EMTALA", revised 8/16. The prior version of the policy indicated it was titled "Emergency Medical Treatment Compliance". The Compliance Officer did not respond to the surveyor's e-mail stating the policy appeared to be an earlier version of the same policy provided during the survey.

Based on interview and record review, the hospital failed to document the type of ambulance (basic life support, advanced life support, or critical care transport) used to transfer 1 of 20 sampled patients (Patient 10). The deficient practice eliminated accountability that the transfer was effected by appropriate means, and had the potential to allow transportation mismatched to patient needs.

Findings:

Review of Patient 10's "ED [emergency department] Note - Physician" dated 6/1/20 indicated Patient 10 was seen at the hospital's ED for a stroke with hemorrhage (bleeding). The note indicated, "Spoke with [outside hospital] stroke neurologist... she has reviewed scans and she agrees with lowering blood pressure, systolic blood pressure less than 140, given hemorrhagic component, can give as needed meds [medications] or nicardipine drip [a continuous infusion of a medication to lower blood pressure] as needed. The note indicated Patient 10 received IV (intravenous) labetalol (a medication to lower blood pressure) at 1:27 a.m., 1:34 a.m., and 2:02 a.m. The note indicated the outside hospital accepted Patient 10 for transfer to ICU (intensive care unit) at 2:27 a.m. Patient 10's medical record included "Stroke Transport Guidelines" dated 6/1/20 from the receiving hospital which indicated "For Intracranial Hemorrhage [bleeding inside the skull]... Keep SBP [systolic blood pressure]< [less than] 140 and > [greater than] 120; DBP [diastolic blood pressure] <90 and >50 CONTACT STROKE PHYSICIAN via TRANSFER CENTER.... if BP outside these parameters. This is essential!" The guidelines included dosages for four different blood pressure medicines to be given only with physician approval. Patient 10's "PATIENT TRANSFER" form dated 6/1/20 indicated Patient 10 was transferred at 3:07 a.m.; the method of transfer, personnel accompanying the patient, vital signs prior to transfer, and information regarding infusions and cardiac monitoring were all left blank. Patient 10's "AUTHORIZATION FOR AND CONSENT TO TRANSFER TO ANOTHER FACILITY / TRANSPORT FOR MEDICAL TREATMENT" dated 6/1/20 had a blank line for the method of transportation. Patient 10's medical record included an "AMBULANCE MEDICAL NECESSITY VERIFICATION FORM" dated 6/1/20 which provided justification for an ambulance but did not specify the type of ambulance to be used.

In an interview on 12/10/20 at 3:22 p.m., the Informatics Registered Nurse (ITRN) stated she was looking for the transport mode in Patient 10's electronic medical record. The ITRN stated the medical necessity verification form did not state the type of ambulance, and that she could not see the level of ambulance in Patient 10's record. The Chief Nursing Officer (CNO) stated she would check whether the house supervisor's log recorded the type of transport used to transfer Patient 10. In an interview on 12/11/20 at 10:28 a.m., the CNO stated Patient 10 was not on the house supervisor's transfer log.