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Based on review of facility documentation and credential files (CF), and employee interviews (EMP), it was determined that the facility failed to ensure that education on the Emergency Medical Treatment and Labor Act (EMTALA) was completed by seven of 15 credentialed providers (CF1, CF4, CF7, CF8, CF11, CF12 and CF13).

Findings include:

Review of Grove City Medical Center Policy, "Medical Screening, Stabilization and Transfer of Emergency Department and Obstetrical Antepartum Patient (EMTALA), Admin 3.14; ED 3.9; MCH 3.77," revised May 2009.

1. Review of the above policy did not reveal a requirement for education of physicians and/or credentialed staff on the requirements listed under EMTALA.

2. Review of the consolidated Medical Staff Meeting minutes dated September 22, 2011, revealed, "CME Presentation: [EMP5], presented education on the following: ... EMTALA ... This education is required annually by the PA Department of Health. The physicians that did not attend will be sent a packet to read and sign off that they understand the education."

On April 29, 2014, at 10:00 AM, EMP5 confirmed that the statement above from the meeting minutes of September 22, 2011, referred to the policy that requires physicians to have the education for EMTALA annually.

3. Review of CF1 revealed no documentation of training and/or education for EMTALA. On August 28, 2014, at 1:05 PM, EMP12 confirmed there was no documentation that the physician associated with CF1 received the required education on EMTALA.

4. Review of CF4, CF7 and CF8 revealed no documentation of the required EMTALA education.

On April 29, 2014, at 11:06 AM, EMP12 confirmed that CF4, CF7 and CF8 had no documentation of the associated physicians having the required education for EMTALA. "I only have for [CF5], [CF6] and [CF9]."

5. A review of physician education for on-call specialists conducted April 30, 2014, revealed CF11, CF12 and CF13 had no documentation of having the required education for EMTALA.

6. At approximately 9:30 AM on April 30, 2014, in response to a request for physician education regarding EMTALA, EMP12 stated, "I thought it was only active staff [that needed EMTALA] education. ... That's why there is none [EMTALA education in CF], because I didn't know [it was required]."

Based on review of facility documentation and employee interviews (EMP), it was determined that the facility failed to establish policies and procedures clearly defining the responsibilities of the on-call physician to respond, examine and treat patients with an emergency medical condition.

Findings include:

During an onsite investigation between April 28 and April 30, 2014, the following policies were reviewed, Policy Admin 3.14, ED 3.9, MCH 3.77, "Medical Screening, Stabilization and Transfer of Emergency Department and Obstetrical Antepartum Patient (EMTALA)," revised May 2009, "Medical Staff Bylaws, Rules & Regulations," reviewed February 27, 2014, Policy ED 1.3, "Physician Guidelines for the Emergency Department," last approved February 2014; and Policy ED 5.2, "Provision of Services for Emergency Department Patients," no review/revise date provided.

1. Review of the above did not reveal policies and/or procedures to define actions in situations in which a particular specialty is not available.

2. Review of the above did not reveal policies and/or procedures to define actions in situations in which the on-call physician cannot respond because of circumstances beyond the physician's control.

3. Review of the above did not reveal policies and/or procedures to provide availability of emergency services to meet the needs of patients with emergency medical conditions if [the facility] elects to permit on-call physicians to schedule elective surgery during the time that they are on-call.

4. Review of the above did not reveal policies and/or procedures to permit or deny on-call physicians the ability to have simultaneous on-call duties.

5. Review of the above did not reveal policies and/or procedures which define "reasonable" response time for on-call physicians.

6. When asked, at approximately 1:00 PM on April 30, 2014, for any policies and/or procedures the facility had established defining physician on-call requirements and/or responsibilities that may not have been provided to the surveyor, EMP5 stated, "There is no on-call policy."

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure that all elements of an appropriate transfer were met for 10 of 20 medical records reviewed (MR1A, MR2, MR3, MR8, MR11, MR19, MR20, MR21, MR22, and MR23) .

Findings include:

Review of the "Grove City Medical Center Grove City, Pennsylvania Medical Staff Bylaws Rules & Regulations Fair Hearing Plan," reviewed February 27, 2014, revealed, "... Grove City Medical Center Medical Staff Bylaws ... Article III - Staff Appointment 3.1 Nature of Appointment ... 3.1-2 Responsibilities of Staff Appointment Each member of the staff, by accepting appointment, shall agree to: ... b. abide by the current Staff Bylaws and rules and regulations, and by other established standards, policies and rules of the Hospital; ... Grove City Medical Center Rules and Regulations ... B. Emergency Services 1. Appointees of the Staff shall accept responsibility for emergency service care in accordance with emergency service policies and procedures. ... 10. An appropriate emergency service medical record shall be kept for every patient receiving emergency service and shall be incorporated in the patient's previous inpatient medical record, if such exists. The emergency service medical record shall include: a. Adequate patient identification; b. Information concerning the time of the patients arrival and by whom transported; c. Pertinent history of the injury or illness including details relative to first aid or emergency care given the patient prior to his arrival at the Hospital and history of allergies; d. Description of significant clinical, laboratory, and X-ray findings; e. Diagnosis including condition of patient; f. Treatment given and plans for management; g. Condition of the patient on discharge or transfer; and h. Final disposition, including instruction given to the patient and/or his family, relative to necessary follow-up care. ... 15. Patients with conditions whose definitive care is beyond the capabilities of this Hospital shall be referred to the appropriate facility, when in the judgment of the attending practitioner, the patient's condition permits such a transfer. The Hospital's procedures for patient transfers to other facilities shall be followed. ..."

Review of Grove City Medical Center Policy, "Medical Screening, Stabilization and Transfer of Emergency Department and Obstetrical Antepartum Patient (EMTALA), Admin 3.14; ED 3.9; MCH3.77," revised May 2009, revealed, "SCOPE: This policy/procedure applies to all individuals who (1) present to the Emergency Department for care ... E. Screening: ... 3. The examination may include those ancillary services routinely available to, although not located in the Emergency Department. 4. The emergency physician on duty shall be responsible for the general care/stability of all patients presenting themselves to the Emergency Department. ... F. Stabilization: 1. "Stabilization" is achieved when no material deterioration is likely to result from the transfer or discharge of the individual, ... 2. An individual experiencing an emergency medical condition must be stabilized before transfer or discharge. G. Transfer: 1. The decision to transfer a patient is based on patient request or the hospital's ability to provide the type and quality of care the patient needs, including availability of resources needed to treat a specific condition or disease. To the extent of the capabilities of the hospital and/or provider based location, provide stabilization, such that the patient is not to deteriorate from or during transport or discharge. ... 3. The condition of each individual transferred shall be documented in the medical record by the physician responsible for providing the medical examination and stabilizing treatment. 4. The transferring department shall provide the receiving facility with appropriate medical records regarding its treatment of the individual that includes, but is not limited to, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of any test, informed written consent or transfer certification."

1. Review of MR1A revealed the patient was transferred on April 13, 2014, to a tertiary facility. Review of the record and the patient transfer record revealed no documentation that copies of the patient's medical record(s) had accompanied the patient on transfer or were forwarded to the receiving facility. Review of the Patient Transfer Record did not have documentation of who contacted the transport service. Further review did not reveal if the patient consented to the transfer or requested not to be transferred.

2. Review of MR2 on April 28, 2014, revealed the patient was transferred by ambulance on April 11, 2014. The Emergency Department Physician Orders sheet and Emergency Physician Record failed to include documentation that the patient was stabilized prior to transfer. Review of the Patient Transfer Record revealed no documentation of the physician's certification for transfer to include stabilized vs non-stabilized but in need of transfer, risks vs benefits of transfer, and/or requirements for specialized transfer.

3. Review of MR3 on April 29, 2014, revealed the patient was transferred by ambulance on March 22, 2014. The Emergency Department Physician Orders sheet and Emergency Physician Record failed to include documentation that the patient was stabilized prior to transfer. Review of the Patient Transfer Record revealed no documentation to indicate if the patient was stable prior to transfer.

4. Review of MR8 on April 29, 2014, revealed the patient was transferred by ambulance on April 13, 2014. The Emergency Department Physician Orders sheet revealed the disposition of the patient was "Transferred," and condition was "Fair." The Emergency Physician Record failed to reveal the patient was stabilized prior to transfer. The Patient Transfer Record revealed no documentation to indicate if the patient was stable prior to transfer.

5. Review of MR11 on April 29, 2014, revealed the patient was transferred on April 7, 2014. The Emergency Department Physician Orders sheet revealed the disposition of the patient was "Transferred," but the condition at time of the disposition was not marked. Review of the Emergency Physician Record revealed the condition at time of transfer was "Serious," but was not marked as stable. The Patient Transfer Record revealed no documentation to indicate if the patient was stable prior to transfer.

6. Review of MR19 revealed the patient was transferred on January 22, 2014, to a tertiary facility. Review of the record and the patient transfer record revealed no documentation that copies of the patient's medical record(s) had accompanied the patient on transfer or were forwarded to the receiving facility. Review of the physician record and the transfer record revealed no documentation of the patient's condition being stabilized at the time of transfer.

7. Review of MR20 revealed the patient was transferred on February 24, 2014, to a tertiary facility. Review of the record and the patient transfer record revealed no documentation that copies of the patient's medical record(s) had accompanied the patient on transfer or were forwarded to the receiving facility.

8. On April 30, 2014, at 2:00 PM, EMP5 confirmed the lack of documentation on MR19 that copies of the patient's medical record(s) had accompanied the patient on transfer or were forwarded to the receiving facility for MR19 and MR20.

9. Review of MR21 revealed the patient was transferred on February 20, 2014, to a tertiary facility. Review of the "Authorization and Transfer Statement," on the "Patient Transfer Record," did not reveal documentation of the patient's name and, "The purpose of this care or treatment is___."

10. Review of MR22 revealed the patient was transferred on February 27, 2014, to a tertiary facility. Review of the "Consent to Patient Transfer," on the "Patient Transfer Record," did not contain documentation whether the patient was signing to request and consent to transfer or to refuse transfer.

11. Review of MR23 revealed the patient was transferred on December 12, 2013, to a tertiary facility. Review of the "Consent to Patient Transfer," on the "Patient Transfer Record," did not contain documentation whether the patient was signing to request and consent to transfer or to refuse to be transferred. Review of the "Authorization and Transfer Statement," on the "Patient Transfer Record," did not reveal documentation of the patient's name and, "The purpose of this care or treatment is___." Review of the Patient Transfer Record revealed no documentation of the physician's certification for transfer to include stabilized vs non-stabilized but in need of transfer, risks vs benefits of transfer, and/or requirements for specialized transfer.