HospitalInspections.org

Based on document reviews and interviews, it was determined that the hospital failed to report to CMS or the State Survey Agency a suspected incidence of an individual transferred in violation of the Emergency Medical Treatment and Labor Act (EMTALA) for one (1) of twenty (20) Emergency Department (ED) records reviewed (Record A).

The finding includes:

On June 28, 2017, the hospital's Physician Advisor for EMTALA gave the surveyors the "Mayo Regional Hospital EMS Patient Care Report" (ambulance run sheet) to review. Documentation on the ambulance run sheet, dated June 8, 2017, indicated Patient A had been taken to Hospital A after falling from playground equipment. The ambulance arrived on the grounds of Hospital A and before unloading the patient, and the patient being seen, a staff member from Hospital A strongly suggested the ambulance crew take the patient to Eastern Maine Medical Center, which they did.

Eastern Maine Health System's Interdepartmental Directive: # 20-085, "Emergency Treatment and Transfer Rules" V.I. ENFORCEMENT AND PENALTIES states, "If the hospital receives a patient in transfer in an unstable emergency medical condition in violation of Part II of this policy, the department head of the receiving unit must contact the Chief, Emergency Medical Service who will determine whether a report must be filed with HCFA, after consultation with the EMHS Vice President and General Counsel."

On June 28, 2017, at 9:55 AM, during an interview with the hospital's Physician Advisor for EMTALA, he verified that EMMC personnel, who were working in the Emergency Department on the evening of June 8, 2017, informed him early on June 9, 2017, that EMMC received a patient from Hospital A, which appeared to be in violation of the EMTALA regulations. On June 9, 2017, the EMMC Physician Advisor for EMTALA discussed the situation with multiple Hospital A personnel involved in the situation. He indicated it was decided that Hospital A would make an entity self-report to the State agency.

On June 28, 2017 at 3:51 PM, during an interview with the Chief Nursing Officer, she explained that it is the practice of EMMC to discuss any suspected EMTALA violations with the sending hospital. When the sending hospital is willing to self-report, it is EMMC's practice to do nothing. If the sending hospital refuses to self-report, then EMMC makes the report. She stated, "We have done this process forever ...that has been our interpretation [of the EMTALA regulations] ...we talk to the Chief Medical Officer always, to re-evaluate our stance".

As of June 29, 2017, the State agency had not received notification from EMMC (the receiving hospital) that there may possibly have been an EMTALA violation.