HospitalInspections.org

Based on observations, interviews, review of patient medical records, review of hospital policies and procedures and other documents, it was determined that the hospital failed to comply with all requirements of 489.24.

Refer to citations and examples at:

A 2402 (489.20(q) Required Signage - Failure to ensure that signs specifying the rights of individuals to receive examination and treatment for emergency medical conditions and women in labor was conspicuously posted in areas likely to be noticed by individuals entering or receiving treatment in the emergency department.

A 2406 (489.24(a) Medical Screening Exam - Failure to have language in by-laws, approved by the Governing Body that specified which medically qualified personnel had been determined qualified to conduct emergency medical exams (MSEs).

A 2407 (489.24(1)(i) Stabilizing Treatment - Failure to provide continued stabilizing treatment to Patient #1, which potentially led to a deterioration in the patient's health status.

A 2409 (489.24. Appropriate Transfer - Failure to ensure a safe and appropriate transfer to Patient #1 which potentially led to a deterioration in the patient's health status.

Based on observations, staff interview and review of hospital policy, it was determined that the hospital failed to ensure that signs specifying the rights of individuals to receive examination and treatment for emergency medical conditions and women in labor was conspicuously posted in areas likely to be noticed by individuals entering or receiving treatment in the emergency department and were written in the required languages. Failure to do so placed patients at risk for violation of their rights.

Findings were:

During a tour of the obstetric (OB) department with administrative staff on 02/15/18 at approximately 2 P.M., it was observed there were no posted signs specifying patient rights to examination and treatment for emergency medical conditions and women in labor present in the entrance to the obstetric department, nor was the required signage present in the 3 rooms identified as the rooms used to triage OB patients.

The nurse manager of the OB department confirmed the lack of signage.

During a tour of the emergency department (ED) with administrative staff on 02/15/18 which began at approximately 2:10 P.M., the ambulance bay entrance was observed. There was no signage at the entrance, except a painted sign on the glass door entrance, which directed ambulatory patients to the front lobby. The Chief Nursing Officer (CNO) and the Chief Quality Officer (CQO) confirmed that the main hospital waiting area was the only entrance to the ED for ambulatory patients, including those who might be bleeding, vomiting or in distress.

The main hospital waiting area was toured and signage was observed in the waiting area. Two signs were observed in the waiting area. One sign was approximately 10 by 12 inches, printed in black and white, and posted on the wall approximately 5 to 6 feet up, in back of a line of wheelchairs. The second sign was the same size, also posted approximately 5 to 6 feet up, in back of a line of chairs in the waiting area. The signs were not obvious and were not readable from a distance of 20 feet and both were in English only.

The ambulance bay was toured and found to not have signage. The glass doors to the ED ambulance bay had a painted signed which directed ambulatory patients to the main lobby.

The ED care area was entered and the bay which contained 2 unoccupied beds was entered. The area had no signage in the area of the beds, but did contain one sign with the same size and placement, written in English only, as those in the main lobby. The sign was near the sink in the area.

The above findings were confirmed by the CNO and the CQO.

The hospital policy and procedure "COBRA/EMTALA Patient Transfers", dated 12/02/2016 and authored by the hospital's general counsel, was reviewed and found to contain the following:

"...3. WHAT EMTALA SIGNAGE IS REQUIRED: Each department that provides Emergency or Clinic Services shall post a sign (English & Spanish) in a place or places likely to be noticed by all individuals entering the department..."

The hospital failed to follow the EMTALA requirement for signage and failed to follow it's own policy on sign placement and required languages for the signs.

Based on staff interview and review of hospital documentation, it was determined that the hospital failed to have language in hospital regulations or by-laws, approved by the Governing Body, that specified which medically qualified personnel had been approved to conduct emergency medical screening exams (MSEs) for the hospital.

Findings:

The hospital policy and procedure "COBRA/EMTALA Patient Transfers", dated 12/02/2016 and authored by the hospital's general counsel, was reviewed and found to contain the following directions regarding MSE's:

"DEFINITIONS:
...12. Medical Screening Examination: is the process required determining, with reasonable clinical confidence, whether or not an emergency medical condition exists or a woman is in labor. This is documented in the patient's medical record..."

"MEDICAL SCREENING EXAMINATION REQUIREMENTS
...f. The medical screening must be performed by a doctor or medicine or osteopathy, a physician's assistant, advanced practice providers including nurse practitioners with hospital privileges and paramedics under authority of EMS Medical control..."

No other policy and procedure regarding MSEs was provided.

The Chief Nursing Officer (CNO) and the Chief Quality Officer confirmed that no mid-level practitioners worked in the ED, and all physicians who worked in the ED, except for one, were board-certified in Emergency Medicine. The CQO stated that that the hospital had nurse practitioners "on the floor" only, and the midwives in the OB department had hospital privileges. She stated that no non-physicians were to do MSEs.

Throughout the 2-day onsite investigation, administrative staff was requested to provide documentation from hospital regulations or by-laws, approved by the Governing Body, that specified which medically qualified personnel had been approved to conduct MSEs. On 02/16/2018 the Chief Quality Officer (CQO) confirmed that comparable language did not exist in current hospital regulations or bylaws or in any other available documentation.

Based on interviews, review of medical records and review of hospital policy, it was determined that the hospital failed to provide continued stabilizing treatment for Patient #1 and forced the unstable patient to leave the hospital. The hospital's failure potentially placed Patient #1 at risk for a decline in health status.

Findings include:

INTERVIEWS:
Complainant:
On 0/20/2018, the complainant stated that Patient #1, a pediatric psychiatric patient, had been admitted to the Emergency Department at Whidbey Health on 02/18/2016. The complainant stated that the patient had been discharged about 2 days earlier, from another hospital, after an inpatient stay for psychiatric care.

The complainant stated that the patient's family had multiple conversations with hospital staff at Whidbey Health, during which they requestd that the patient be admitted to the hospital, or transferred to another hospital via ambulance. The complainant stated that on 02/19/2016, Staff #1, a hospital social worker, told the patient and her/his family that they "had to go", and could not stay in the hospital.

The complainant stated that the family was told by Physician #1 that the patient could not be admitted, and no ambulance would be provided. S/he stated that after the physician made the statement to the patient's family, the physician left the room and never came back.

S/he stated that after waiting about 20 minutes, the family member went back to the patient's room to look for someone, but could find no one. S/he stated that security came to the ED and stood by while the family gathered their belongings. The complainant stated that s/he asked for a specific nurse, but could not find the nurse. S/he stated the family left with no paperwork.

The complainant stated that the family took Patient #1 to the ED of the hospital where s/he had previously been an inpatient and the patient was admitted as an inpatient. S/he stated that, due to seizures and hallucinations, the patient had had to be held down for the entire hour and a half trip.

Social Worker #1
On 02/23/2018, social worker #1 stated that the CNO [at the time] and Physician #1 had both told her/him that the patient "had to go" and s/he thought that meant immediately. When asked if it was her/his role to tell patients/families that they "had to go", s/he stated that s/he would deliver that message if s/he "had a rapport" with the families, but "others" made that decision. When asked to confirm her statement that s/he would tell a patient/family that they "had to go" if s/he felt a rapport with the patient/family, s/he stated that s/he did not recall delivering that message to others, just this patient/family.

CQO [formerly the CNO]
On 02/15/2018, the CQO stated that the hospital had psychiatric patients stay in the ED "all of the time", so telling a patient/family that they "have to go" is not a usual hospital practice. S/he stated that the hospital sees approximately 1,000 psychiatric patients per year and many of them stay in the ED until an appropriate bed can be found. S/he stated that the hospital does not have a psychiatric service, or a pediatric service and, at the time Patient #1 was in the ED, the hospital did not have the services of a psychiatric telemedicine consultant. Because the hospital could not meet the needs of the patient, s/he could not be admitted as an inpatient, but could have been cared for in the ED until appropriate placement could be found.

Physician #1/ED Medical Director
On 02/16/2018, Physician #1 stated that s/he did not recall the patient because s/he had not taken care of the patient and had not seen her/him. S/he stated he had been asked to talk to the parents after they were already upset.

Physician #1 stated that he did not discharge the patient, or tell the patient/family, or anyone else, that the patient "had to go". S/he confirmed that s/he had read the documentation from social worker #1 and "this isn't the normal way things go in the ED".

Medical Record Review
Review of the medical record for the ED visit of 02/18/2016 for Patient #1 revealed that the patient was a pediatric, psychiatric patient. The patient had been a recent inpatient at another hospital, where s/he had received psychiatric services, having been discharged approximately 2 days prior to arriving at the Whidbey Health hospital.

Documentation of the ED visit for 02/18/2016 admission history and physical revealed that the patient had diagnoses which included suicidal ideation, hallucinations, pseudo seizures and aggressive behavior. On the evening of admission to the ED, the patient had "...violently beat up on [her/his] 6'4" father...out of control requiring ambulance transport to the ED..."

Review of the medical record showed that on 02/19/2016, social worker #1 documented at 18:37 [6:37 P.M.] that "...ED supervisor, ED chief physician and CNO discussed the pt's case and determined that pt's needs were not being met at WGH and pt had no medical needs to attend to and needed to discharge home. CNO reported to SW that pt "needs to go". SW informed CNO that SW was on [her/his] way to discuss this decision with parents...SW also informed the parents that hospital administration and been involved and determined pt. was not able to stay in the ED while SW searched for a bed. Parents were very upset with this decision..."

Review of the medical record showed that as of 7:00 A.M. the next day, 02/19/2016, care of the patient was assumed by Physician #3. The physician documented that the patient had gotten agitated, had started to yell, and when the physician spoke with the patient, the patient had said that s/he "...just wanted to die..." At 4:45 P.M. "...family left with pt. without my knowledge".

Review of the 02/19/2016 admission history and physical for the patient, at the same hospital from which s/he had been recently discharged, showed that the patient was admitted as an inpatient the same day s/he left Whidbey Health.

The physician at the admitting hospital documented that the patient was brought back to that hospital's ED due to "...continuing self-injurious behavior, agitation and aggressive behavior in the setting of increasing anxiety and reports of seeing and hearing distressing things..."

The hospital policy and procedure "COBRA/EMTALA Patient Transfers", dated 12/02/2016 and authored by the hospital's general counsel, was reviewed and showed the following directives to staff:

"DEFINITIONS:
...14. Stabilize: refers to providing medical treatment of the patient's condition necessary to assure, within reasonable medical probability that no material deterioration of the condition is likely to result from or occur during a transfer of the individual from a facility..."

The above referenced interviews and review of medical records appeared to confirm that the hospital did not provide necessary stabilizing treatment before the patient/family were told that they "had to go" from the hospital and the patient's condition did deteriorate as a consequence.

Reference citation at Tag C 2409

Based on interviews, review of medical records and hospital policy, it was determined that the hospital failed to ensure safe and appropriate transfers for 9 of 25 patients whose medical records were reviewed (Patient #1, 6, 7, 9, 12, 14, 15, 21 and 25). The hospital's failure to do so potentially resulted in a deterioration in health status for Patient #1, and potentially placed other transferred patients at risk for same.

Findings include:

Patient #1

Interviews:
Complainant:
On 0/20/2018, the complainant stated that Patient #1, a pediatric psychiatric patient, had been admitted to the Emergency Department (ED) at Whidbey Health on 02/18/2016. The complainant stated that the patient had been discharged about 2 days earlier, from another hospital, after an inpatient stay for psychiatric issues.

The complainant stated that the patient's family had multiple conversations with hospital staff at Whidbey Health about admitting the patient, or transferring the patient to another hospital via ambulance. The complainant stated that on 02/19/2016, Staff #1, a hospital social worker, told the patient and her/his family that they "had to go", and could not stay in the hospital.

The complainant stated that the family had been told by Physician #1 that the patient could not be admitted, and no ambulance would be provided. S/he stated that after the physician made the statement to the patient's family, the physician left the room and never came back.

S/he stated that after waiting about 20 minutes, the family member went back to the patient's room to look for someone, but could find no one. S/he stated that security came to the ED and stood by while the family gathered their belongings. The complainant stated that s/he asked for a specific nurse, but could not find the nurse. S/he stated the family left with no paperwork.

The complainant stated that the family took Patient #1 to the ED of the hospital where s/he had previously been an inpatient and the patient was admitted. S/he stated that, due to seizures and hallucinations, the patient had had to be held down for the entire hour and a half trip.

Social Worker #1
On 02/23/2018, the social worker was interviewed by phone, in the presence of the Chief Nursing Officer (CNO) and the Chief Quality Officer (CQO). The CQO stated that during the ED visit of Patient #1, on 02/18-19/2016, s/he had been the CNO.

Social worker #1 stated that the CNO [at the time] and Physician #1 had both told her/him that the patient "had to go" and s/he thought that meant immediately. When asked if it was her/his role to tell patients/families that they "had to go", s/he stated that s/he would deliver that message if s/he "had a rapport" with the families, but others made the decision. When asked to confirm her statement that s/he would deliver the message that a patient/family "had to go" if s/he felt a rapport with the patient/family, she stated that s/he did not recall delivering that message to others, just this patient/family.

The social worker confirmed that s/he had seen the documentation from the DMHP that stated an appropriate bed was available on 02/19/2016. S/he was asked to reconcile that documentation with telling the patient/family that they "had to go". S/he stated that the family had told her/him there was a bed available at a specific facility, but s/he had called that facility, and was told that a bed was not available.

The social worker confirmed that it was her/his practice to document the conversations of others, as s/he did when she documented a conversation between the "...ED supervisor, ED chief physician and CNO..." who said that the patient "had to go".

Social Worker Supervisor
On 02/16/2018, the supervisor of social worker #1, stated that s/he had been briefed on the focus of the investigation and had since reviewed the documentation in the medical record.

The supervisor stated that s/he believed that Patient #1 was going to be admitted to another facility the next day, per the DMHP documentation of a bed availability on 02/19/2016. When asked how the patient being potentially admitted would reconcile with telling the patient/family "they had to go", s/he stated that the "charting doesn't make sense". She stated that s/he believed there were problems with the social worker understanding her/his scope of practice, understanding of her/his role, documenting the conversations of others and an "incorrect interpretation of the process".

CQO [formerly the CNO]
On 02/15/2018, the CQO stated that the hospital has psychiatric patients stay in the ED "all of the time", so telling a patient/family that they "have to go" is not a usual hospital practice. S/he stated that the hospital sees approximately 1,000 psychiatric patients per year and many of them stay in the ED until an appropriate bed can be found. S/he stated that the hospital does not have a psychiatric service, or a pediatric service, and so Patient #1 could not be admitted as an inpatient at Whidbey Health hospital.

S/he stated that the hospital could not/cannot admit psychiatric patients who do not have medical care needs, and social worker #1 may have misunderstood that. S/he stated that s/he did not have any conversation with the social worker in which s/he directed the social worker to give a patient/family the message that they "have to go", and when s/he did get involved in patient care issues, s/he documented her/his own conversations.

The CQO stated that no "AMA" form had been completed, as was hospital policy when patients/families left the hospital against medical advice, nor had the event triggered an incident report.

Physician #1/ED Medical Director
On 02/16/2018, Physician #1 stated that s/he did not recall the patient because s/he had not taken care of the patient and had not seen the patient. S/he stated he had been asked to talk to the parents after they were already upset.

Physician #1 stated that he did not discharge the patient, or tell the patient/family, or anyone else, that the patient "had to go". S/he confirmed that s/he had read the documentation from social worker #1 and "this isn't the normal way things go in the ED". S/he stated that when he met with the patient's family, the person s/he spoke with was very upset and the physician thought that there had been poor communication between the social worker and the DHMP, as well as with the family.

Medical Record Review
Review of the medical record showed that on 02/19/2016, social worker #1 documented at 18:37 [6:37 P.M.] that "parents reported to SW [social worker] that they did not feel safe taking child home as [s/he] has attempted to jump out of the window of moving vehicles, swallow bobby pins, stab [her/him]self with a fork, and attack [her/his] parents. Parents report that this has been pt's pattern for the last 4 weeks..."

The social worker also documented that s/he had informed the patient/family that they "had to go" and the "...parents left the hospital without any DC [discharge] paperwork."

The social worker did not document that s/he had informed the registered nurse caring for the patient about her/his directive to the parents.

The medical record did not contain evidence that the patient/family had been provided with discharge instructions or an opportunity to complete an AMA [against medical advice] form.

Patient #6
Patient #6 was a newborn baby who was transferred to another hospital because the baby was born with signs of withdrawal.
The medical record did not contain a form regarding the medical necessity for the transfer.

Patient #7
Patient #7 was a newborn baby who was transferred to another hospital because the baby was born with signs of withdrawal.
The medical record did not contain a form regarding the medical necessity for the transfer.

Patient #9
Patient #9 was an adult psychiatric patient who was suicidal. The patient was transferred to another hospital for psychiatric care. The order for transfer contained the directive to "restrain PRN".
The medical record did not contain a form regarding the medical necessity for the transfer.

Patient #12
Patient #12 was a patient who was transferred to another hospital for care and treatment of vaginal bleeding, suspected to be cancerous.
The medical record did not contain a form regarding the medical necessity for the transfer.

Patient #14
Patient #13 was a pediatric patient who was transferred to another hospital for psychiatric care.
The medical record did not contain a form regarding the medical necessity for the transfer.

Patient #15
Patient #15 was a patient who was transferred to another hospital for care related to a suspected stroke.
The medical record did not contain a consent form with the potential risks and benefits explanation.

Patient # 21
Patient #21 was a 6-day old patient, transferred to another hospital for care related to an alteration in responsiveness.
The medical record did not contain a consent form with the potential risks and benefits explanation. The medical necessity form had an illegible initial after "signature: attending physician. discharge planner" and an illegible name under "printed name of physician ordering ambulance services".

Patient #25
Patient #25 was transferred to another hospital for care related to a heart attack.
The medical record did not contain a consent for transfer, with the potential risks and benefits explanation.

The above findings were confirmed with the CNO and/or the CQO at the time of the onsite investigation.

On 02/15 and 02/16/2018, personnel in the obstetrical unit and the ED were able to describe the required medical necessity and transfer/consent forms, and to provide samples of each. Personnel did not differentiate between stable/unstable patients when describing the required forms for transfer.

The hospital policy and procedure "COBRA/EMTALA Patient Transfers", dated 12/02/2016 and authored by the hospital's general counsel, was reviewed and found to contain the following:

"DEFINITIONS:
...16. Transfer: means the movement of a living patient to another facility at the direction of any person employed by the clinic or hospital, but does not include such movement of an individual who has been declared dead or who leaves the facility against medical advice (AMA) or without being seen (AWOL)...
b. TRANSFERS FROM WGH:..
i...Physician or provider making the transfer decision will review transfer risks and benefits with the patient and/or family. Appropriate EMTALA documentation is to be provided for all transfers.
ii.Transfer of an unstable individual can take place only when the conditions of an appropriate transfer are met:
iii. The individual request (sic) transfer to another medical facility in writing after being informed of the hospital's obligation under the act (EMTALA) and of the risks of transfer.
iv. A physician has signed a certification that, based upon information available at the time of transfer, the medical benefits expected from treatment at another facility outweigh the risks of transfer..."