HospitalInspections.org

Based on review of facility policy, medical record (MR) and interviews with staff (EMP) it was determined that The Good Samaritan Hospital failed to follow their adopted policies in relation to the Emergency Medical Treatment And Labor Act (EMTALA).

Findings include:

A review on December 20, 2010, of the Good Samaritan Health System policy entitled, Request for and Provision of Emergency Care revealed, "Policy: Individuals requesting or requiring emergency aid are given appropriate assessment and treatment within the capabilities of the site and within the rules of the Emergency Medical Treatment and Labor Act ... III. Responsibilities ED and New Beginnings personnel are responsible to follow policies concerning medical screening, stabilization, admissions, and transfer policies ... V. Procedures ... 1. Patients who present requesting or needing emergency care are directed or taken to the ED ... 2. The MSE is initiated by the ED ... 3. patients with an emergency medical condition are stabilized prior to transfer or discharge ..."

A review on December 20, 2010, of the Pennsylvania EMS report dated November 26, 2010, revealed "DISP: to ... for a cardiac arrest-child ... ENRT: transport class 1 to GSH er due to being closest facility to stabilize pt, upon calling report to GSH er an speaking to an RN they except, 2-3 mins later GSH recontacts ALS and states we need to divert to HMC, due to being 1-2 mins from GSH er transport is continued where we are met outside and told by Dr. ... to divert to HMC ... "

An offsite review on December 21, 2010, of PT1 revealed the patient presented to Milton S Hershey Medical Center on November 26, 2010, at 1:27 AM by ambulance. Further review of PT1 revealed "11/26/2010 03:23 ... pt being admitted at IMC ... "

An interview conducted on December 20, 2010, at 1:05 PM with EMP10 confirmed that the 11 month old male was brought to the emergency department by ambulance on November 26, 2010, was not entered on the emergency room log, no medical record containing a medical screening examination was documented and no patient transfer was created.

Based on review of the The F.J.Dixon Emergency Center central log and interview with staff (EMP), it was determined the facility failed to ensure that a central log entry was generated on each individual who came to the Emergency Department, seeking assistance, whether or not the individual was refused treatment, transferred or stabilized and transferred for one of one patent reviewed (PT1).

Findings include:

A review on December 20, 2010, of the F. J. Dixon Emergency Center Policy and Procedure Manual policy entitled "Patient Registration" revealed, " ... It is the policy ... that every patient who requests and receives any medical and/or nursing services shall have a medical record for each visit. The patient will be identified with a wrist bracelet ... "

A review on December 20, 2010, of the emergency department log for November 26, 2010, revealed that PT1 was not listed on the log.

An interview conducted on December 20, 2010, at 1:05 PM, with EMP10 confirmed that PT1 had not been entered onto the log.

Based on review of facility policies, documents and interview with staff (EMP), it was determined that The Good Samaritan Hospital failed to document an appropriate medical screening examination by qualified medical personnel to an individual seeking examination and failed to effect an appropriate transfer for one patient that presented to the Emergency Department. (PT1).

Findings include:

A review on December 20, 2010, of the F. J. Dixon Emergency Center Policy and Procedure Manual policy entitled, Medical Screening revealed, " ... every patient presenting for emergency care receives a medical screening exam ... D. The treating physician ... completes the medical screening exam and documents findings on the ED record ... "

A review on December 20, 2010, of the F. J. Dixon Emergency Center Policy and Procedure Manual policy entitled, Transfer of ED Patients revealed, " ... 1. The individual or responsible party request and consent to the transfer in writing, or 2. The responsible physician has determined that the benefits of transfer to the individual outweigh the risks, and has signed a certification summarizing this assessment, and 3. An appropriate transfer can be accomplished, to include: a. Acceptance by a facility having available space and qualified personnel, b. Provision to the receiving hospital of all medical records and results relating to the emergency condition as well as all consents and physician certifications..."

A review on December 20, 2010, of the Pennsylvania EMS report dated November 26, 2010 revealed, "DISP: to ... for a cardiac arrest-child ... ENRT: transport class 1 to GSH er due to being closest facility to stabilize pt, upon calling report to GSH er an speaking to an RN they except, 2-3 mins later GSH recontacts ALS and states we need to divert to HMC, due to being 1-2 mins from GSH er transport is continued where we are met outside and told by Dr. ... to divert to HMC ... "

An offsite review on December 21, 2010, of PT1 revealed the patient presented to Milton S Hershey Medical Center on November 26, 201, at 1:27 AM by ambulance. Further review of PT1 revealed "11/26/2010 03:23 ... pt being admitted at IMC ... "

An interview conducted on December 20, 2010, at 1:05 PM with EMP10 confirmed that no medical record was created and that an appropriate transfer was not completed for PT1.

Based on review of documents and interview with staff (EMP) and others (OTH), it was determined that the facility failed to provide a medical screening examination and treatment and stabilization of an emergency medical condition within its capability and capacity for one patient presenting to their Emergency Department (PT1).

Findings include:

A review on December 20, 2010, of the F. J. Dixon Emergency Center Policy and Procedure Manual policy entitled Medical Screening revealed, "... every patient presenting for emergency care receives a medical screening exam ... D. The treating physician ... completes the medical screening exam and documents findings on the ED record ... "

A review on December 20, 2010, of the Pennsylvania EMS report dated November 26, 2010 revealed, "DISP: to ... for a a cardiac arrest-child ... ENRT: transport class 1 to GSH er due to being closest facility to stabilize pt, upon calling report to GSH er an speaking to an RN they except, 2-3 mins later GSH recontacts ALS and states we need to divert to HMC, due to being 1-2 mins from GSH er transport is continued where we are met outside and told by Dr. ... to divert to HMC ... "

A telephone interview on December 20, 2010, at approximately 1:30 PM with OTH1 stated "We were contacted to divert to Hershey ... I informed the doctor that we were continuing in that I wanted the child stabilized ... Dr. ... was waiting outside for us when we backed into the bay ... "
A telephone interview on December 20, 2010, at approximately 1:45 PM with OTH2 stated "I informed the doctor that the 'baby was in the truck' ... "
An interview conducted on December 20, 2010, at 1:05 PM with EMP10 confirmed that a medical screening examination and treatment was not documented for PT1.

Based on review of facility documents, ambulance records, and interview with staff (EMP), it was determined The Good Samaritan Hospital failed to provide a proper transfer to another facility for one patient transferred from their Emergency Department (PT1).

A review on December 20, 2010, of the "F. J. Dixon Emergency Center Policy and Procedure Manual" policy entitled, Transfer of ED Patients revealed, " ... 1. The individual or responsible party request and consent to the transfer in writing, or 2. The responsible physician has determined that the benefits of transfer to the individual outweigh the risks, and has signed a certification summarizing this assessment, and 3. An appropriate transfer can be accomplished, to include: a. Acceptance by a facility having available space and qualified personnel, b. Provision to the receiving hospital of all medical records and results relating to the emergency condition as well as all consents and physician certifications ... "

A review on December 20, 2010, of the facility's Emergency Department log for November 26, 2010, revealed no documentation that PT1 presented to the ED and/or that transfer arrangements were made for PT1.

A review on December 20, 2010, of the Pennsylvania EMS report dated November 26, 2010 revealed, "DISP: to ... for a a cardiac arrest-child ... ENRT: transport class 1 to GSH er due to being closest facility to stabilize pt, upon calling report to GSH er an speaking to an RN they except, 2-3 mins later GSH recontacts ALS and states we need to divert to HMC, due to being 1-2 mins from GSH er transport is continued where we are met outside and told by Dr. ... to divert to HMC ... "

3) An interview conducted on December 26, 2010, at 1:05 PM with EMP5 confirmed that PT1 was brought by ambulance to the emergency department on November 26, 2010. Further interview confirmed the transfer was not documented.