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Based on staff interview, clinical record review, policy and procedure review, and in the course of a complaint investigation, it was determined that the facility staff failed to comply with the special responsibilities of Medicare hospitals in emergency cases. The facility staff failed to provide evidence of appropriate medical screening examinations for 4 of 20 patients, and failed to follow requirements for transfer for 3 of 3 patients transferred to psychiatric hospitals.

The findings include:

1. A review of the clinical records for Patient's #6, #8, #9 and #10 revealed the medical screening examinations (MSE) were incomplete. The MSE notes were void of a review of systems and physical examination. The reports did include laboratory tests results, etc. that populated the report from other areas in the computer.

MD #1 was the physician responsible for each of the above individuals. The survey team met with the physician on 1/7/10 from 9:43 AM through 10:35 AM. The discussion included MSE's, documentation in general and specifically for Patient #6.

MD #1 stated the ED protocol was for the physician to do an initial assessment of the individual, give orders, and then follow up with a re-assessment according to the results of laboratory tests and diagnostic studies.

The physician described the computer documentation system, which was implemented in June 2009. The ED documentation had been on paper prior to June. The physician stated that he sometimes filled in the MSE assessment, and then hit a wrong button, deleting the information.

Incomplete charts were flagged by the computer system and put in the physician's "in box" or in basket to be addressed at a later time.

MD #1 stated he remembered putting the MSE information in the computer for Patient #6 and verified that the hard copy (and computerized record) did not have the information. When reviewing the record, it looked as if a review of systems and physical examination had not been done.

The survey team met with the Director of Clinical Effectiveness (QAPI nurse) and Chief Nursing Officer (CNO), on 1/7/10 at 1:47 PM, to discuss the facility's performance improvement program. The QAPI nurse stated "issues with inadequate documentation" had been discussed in the senior leadership committee, "particularly on the ER charts".

The nurse stated that she planned to address concerns about documentation with the medical executive committee later in January 2010. Minutes of the medical executive committee meeting revealed that physician documentation was also discussed in October 2009.

The managers stated that approximately three plans had been developed to address physician lack of documentation. MD #1 and other physicians as well, were sent to another hospital for additional training on the computer system. Another meeting with MD #1 had been planned prior to the start of the survey. A review of the personnel file revealed that documentation issues had been addressed with the physician in September 2009.

The CNO stated that the contract service for the emergency department physicians had been contacted "many, many times" regarding a need for performance improvement related to documentation. The surveyors talked with four members of the ED physician ' s contract company, on 1/7/10 at 10:45 AM. The surveyors were informed that the ED physicians were independent contractors and not employees of the company. The company spokesperson stated assistance was provided with performance improvement, if requested by the hospital.

Please refer to ?489.24(a) for additional information.

2. For 3 of 3 individuals transferred to psychiatric hospitals (Patient's #6, #12, and #19), the facility discharged the individuals instead of following the EMTALA requirements for transfer.

The survey team met with the Chief Nursing Officer (CNO) and the House Supervisor on 1/8/10 at 12:25 PM. The CNO and RN explained the emergency department staff considered individuals transferred from the ED to a psychiatric hospital to be a discharge, not a transfer.

The House Supervisor stated the EMTALA transfer forms or processes were not used for any psychiatric transfers. On the afternoon of 1/8/10, she stated that Patient's #6, #12, and #19 did not have EMTALA transfer forms.

On 1/8/10 at 3:01 PM, the Chief Nursing Officer informed the survey team that the local Community Service Board (CSB) had instructed the hospital staff that they did not need to be involved in making arrangements for patient transfers to psychiatric hospitals. The CSB made the initial contacts with the psychiatric hospitals and took responsibility for relaying information such as laboratory test results, or medical clearance from the ED to the hospital. This had been the process, for years, whether the patient was going directly from the ED to a psychiatric hospital, or was going to a non-hospital facility.

Please refer to ?489.24(e) for additional information.

Based on staff interview, clinical record review, policy and procedure review, and in the course of complaint investigation, it was determined that the facility staff failed to provide evidence of a medical screening examination (MSE) for 4 of 20 individuals in the survey sample, Patient ' s #6, #8.#9, and #10.

The findings include:

Patient #6 arrived at the emergency department on 10/9/09 at 7:54 PM, for medical clearance prior to transfer to a psychiatric hospital. The physician note (MD #1) was dated 10/9/09 at 11:00 PM. The MSE note contained only the information automatically populated from other information in the computer, such as laboratory results and vital signs. The areas titled ROS (review of systems) and Physical Exam were blank. On 1/6/10 at 11:35 AM, the House Supervisor stated the MSE for Patient #6 had "nothing but labs".

Patient #8 arrived at the ED on 10/29/09 at 5:21 PM, with a chief complaint of shortness of breath. The acuity level was assessed as "emergent." The physician note, by MD #1, included a review of symptoms that stated, "Respiratory: Is experiencing shortness of breath." No other evidence of a review of systems, or physical examination by the physician was found. On 1/7/10 at 1:15 PM, the House Supervisor acknowledged that the only MSE documented was the shortness of breath and laboratory results.

According to the clinical record, MD #1 was the physician from 7:36 PM through 10:17 PM. Another physician was responsible after 10:17 PM. The patient was subsequently transferred to another hospital. A nurse documented that phone calls about transferring the patient occurred on 10/29/09 at 10:20 PM. It was unknown, from the record, which physician had initiated the patient transfer.

Patient #9 was seen in the ED on 10/31/09 for a chief complaint of altered mental status. . The clinical record included three notes by MD #1. The first note was dated 10/31/09 at 7:03 PM. The areas for review of systems and physical exam were blank. The items included in the note were the areas automatically populated from other areas of computer information.

A second note by MD #1 was dated 11/9/09 at 1:54 PM and a third note on 12/7/09 at 7:42 AM. No additional information was found in the second and third notes.

Patient #10 was seen in the ED on 11/9/09 at 8:23 PM, with a chief complaint of altered mental status. MD #1's note was dated 11/10/09 at 6:10 AM. The note did not include a review of systems or a physical exam.

The clinical records for Patient's #8, #9, and #10 were reviewed after the interview with MD #1.

The surveyor reviewed the hospital policy and procedure titled 'Transfer, Medical Screening, Stabilization, and Patient Transfer - EMTALA'. In the section titled 'Procedure', point B 1a, addressed triage. "Triage in not a medical screening examination; it is used to assign treatment priority and level of service needed."

Point 2 addressed 'Medical Screening'. "Any individual who comes to the ED requesting care will be provided with a medical screening to determine whether that individual is experiencing an emergency medical condition. In point 2c I, "All patients who come to the ED or elsewhere in the Hospital requesting care or for whom care is requested will be examined by a qualified medical person as determined by the specific Hospital Board. The ED physician on duty shall be responsible for the general care of all patients presenting themselves to the ED."

The 'Assessment/Reassessment - Emergency Services (Physician)' policy and procedure was reviewed. Medical History - "All patients presenting to Emergency Services shall have a medical history assessment pertinent to their clinical needs. Documentation of the medical history shall be made at the time of the patient visit in the EMR (Electronic Medical Record). Physical Exam - "A physical examination whose scope and content relate to the patient's chief complaint, medical history, and condition, and is designed to provide the information necessary to diagnose and/or treat the patient's immediate needs, as determined by the practitioner's clinical judgment shall be completed for all emergency services patients." Reassessment of Patient - "The patient is reassessed as to the patient's clinical condition and response to treatment."

The survey team interviewed the physician responsible for Patient's #6, #8, #9, and #10 (MD #1), on 1/7/10 from 9:43 AM through 10:35 AM. The survey team asked MD #1 about the process for physician assessments of individuals in the ED. The physician stated an initial assessment was done, orders given, and then follow up with a reassessment as diagnostic tests indicated.

A surveyor asked if a physical exam, by the physician, was done for individuals visiting for medical clearance, such as Patient #6. MD #1 acknowledged that all individuals arriving in the ED and requesting services would receive a medical screening examination.

MD #1 stated that he did remember Patient #6 and remembered doing a MSE on the patient. He stated that he saw the patient several times during the time he was in the ED. The physician stated that he did remember putting the MSE information in the computer but may have hit a wrong button and deleted the findings.

The physician stated that he specifically remembered doing an assessment after the Patient #6 fell in the ED.

The physician described the computer documentation system, which was implemented in June 2009. The ED documentation had been on paper prior to June. The physician stated that he sometimes filled in the MSE assessment, but the information would not be saved.

Incomplete charts were flagged by the computer system and put in the physician's "in box" or in basket to be addressed at a later time.

MD #1 stated the clinical record for Patient #6 (hard copy and electronic) did not include a MSE. When reviewing the record, it looked as if a review of systems and physical examination had not been done.

The survey team met with the Director of Clinical Effectiveness (QAPI nurse) and Chief Nursing Officer (CNO), on 1/7/10 at 1:47 PM, to discuss the facility's performance improvement program. The QAPI nurse stated "issues with inadequate documentation" had been discussed in the senior leadership committee, "particularly on the ER charts".

The nurse stated that she planned to address concerns about documentation with the medical executive committee later in January 2010. Minutes of the medical executive committee meeting revealed that physician documentation was also discussed in October 2009.

The managers stated that approximately three plans had been developed to address physician lack of documentation. MD #1 and other physicians as well, were sent to another hospital for additional training on the computer system. Another meeting was to be planned with MD #1. A review of the personnel file revealed that documentation issues had been addressed with the physician in September 2009.

Based on staff interview, clinical record review, and in the process of complaint investigation, it was determined that the hospital staff failed to follow EMTALA transfer requirements for 3 of 3 individuals, in the survey sample, who were transferred to psychiatric hospital facilities (Patient's #6, #12, and #19).

The findings include:

The survey team met with the Chief Nursing Officer (CNO) and the House Supervisor on 1/8/10 at 12:25 PM. The CNO and RN explained the emergency department (ED) staff considered individuals transferred from the ED to a psychiatric hospital to be a discharge, not a transfer.

The House Supervisor stated the EMTALA transfer forms or processes were not used for any psychiatric transfers. On the afternoon of 1/8/10, she stated that Patient's #6, #12, and #19 did not have EMTALA transfer forms.

Review of clinical records did indicate that the EMTALA transfer requirements were followed when individuals were transferred for medical reasons.

On 1/8/10 at 3:01 PM, the Chief Nursing Officer informed the survey team that the local Community Service Board (CSB) had instructed the hospital staff that they did not need to be involved in making arrangements for patient transfers to psychiatric hospitals. The CSB made the initial contacts with the psychiatric hospitals and took responsibility for relaying information such as laboratory test results, or medical clearance from the ED to the hospital. This had been the process, for years, whether the patient was going directly from the ED to a psychiatric hospital, or was going to a non-hospital facility.

Patient #6 arrived in the ED on 10/9/09, for medical clearance, prior to being transferred to a psychiatric hospital. The patient was evaluated by the CSB prior to arriving in the ED. Laboratory tests, a chest x-ray, and an EKG were done while the patient was in the ED.

According to the discharge instructions in Patient #6' s clinical record, " May transfer or place to proper mental institution." "Lab test, cxr, ekg and card. Enz., -cleared."

The LPN (licensed practical nurse) who provided care for Patient #6 was interviewed by the survey team on 1/6/10 at 3:42 PM. LPN #1 stated that law enforcement had transferred the patient from the ED to the psychiatric hospital. This was not found in the clinical record, though the demographic sheet indicated the patient had been discharged at 3:39 AM on 10/10/09. No documentation was found of the physician making contact with the receiving hospital.

According to the ED log, Patient #12 arrived in the ED on 11/29/09 with a chief complaint of suicidal ideation. On 11/29/09 at 1:53 PM, a nurse documented a CSB worker was evaluating the individual. The clinical record included a form titled 'Uniform Preadmission Screening Form' and listed Patient #12 as "TDO." The form indicated that the CSB worker contacted and made arrangements for Patient #12 to be transferred to an inpatient psychiatric facility.

Patient #19 was evaluated at the ED on 12/24/09, due to a chief complaint of anxiety and depression. A physician noted the CSB "had made arrangements for her to be transferred to (name of hospital) on a TDO."

The surveyor reviewed the policy and procedure titled 'Transfer: Medical Screening, Stabilization and Patient Transfer - EMTALA'. The policy was last updated in July 2009. The procedure addressed the need for the ED to obtain consent from the receiving hospital and the requirement for a physician order for transfer. "The condition of each patient transferred shall be documented in the medical record by the physician responsible for providing the medical examination and stabilizing treatment and the Transfer/EMTALA form will be completed, including a summary of the risks and benefits of the transfer. The Transfer/EMTALA form must be signed by the physician or by someone authorized to sign on his/her behalf prior to the transfer".

The section titled 'Patient Transfers to Other Hospitals' did not indicate any change in procedure when the individual was to be transferred to a psychiatric hospital.

On 1/8/10, the survey team asked for a policy and procedure related to psychiatric transfers. The CNO explained that the hospital did not have the requested policy. The survey team then asked staff to provide in writing the ED practice for transfers of mental health patients.

Later on 1/8/10, the hospital staff provided a paper titled 'CTCH Workflow for Mental Health Patients'. According to the work flow form, when individuals were medically cleared, the CSB screener evaluated the individual and determined if criteria for a mental health admission was met If so, the CSB screener "will make arrangements needed with the appropriate institution." "The CSB arranges the transportation for the patient." The House Supervisor had previously informed the survey team that individuals transferred to psychiatric hospitals were transported by law enforcement.

RN #1 also wrote the process for mental health individuals in the ED. She described the process for contacting the CSB screener for an evaluation. The CSB screener informed the ED staff if an inpatient admission was needed. "They (CSB screener) will ask for a copy of lab and xray reports. When ever (sic) a facility accepts pt they will give us a copy of all papers and then the police will be sent out to ED to accompany pt to wherever they will be going. We discharge the pt they are not a transfer."