HospitalInspections.org

Based on observations, staff interview, and review of policy and procedure, it was determined that the facility failed to post EMTALA signage in places seen by patients entering the emergency department (ED) and in conspicuous areas for patients waiting to be treated or examined.

Findings include:

Reference: Policy titled, "Emergency Care & Transfers of Individuals with Emergency Medical Conditions (EMTALA)" states, "...Procedure: ...14. [Health Care System] will conspicuously post signs in all EDs and in places likely to be noticed by all individuals entering EDs, as well as those individuals waiting for examination and treatment, including at the entrances, admitting areas, waiting rooms and treatment areas, specifying the rights of the individuals under EMTALA to receive a medical screening examination and to receive stabilizing treatment (including for an unborn child)....."

1. A tour of the ED was conducted on 11/16/2020 from 10:58 AM to 12:12 PM in the presence of Staff #3. The following areas of the ED were observed to not have EMTALA signage:

a. The fast track area which was noted to contain four (4) separate patient bays.

b. The following designated hallway bed areas: 1H, 2H, 5H, 8H, 10H, 14H, 25H, 27H, and 28H.

c. The following ED rooms: 27, 28, 29, and 30.

2. The above findings were confirmed by Staff #3 at the time of discovery.

3. A tour of the main lobby was conducted on 11/16/2020 at 12:13 PM in the presence of Staff #3. Staff #3 confirmed that the main lobby did not have EMTALA signage posted.

A. Based on staff interview, document review, and review of the facility's medical staff rules and regulations, it was determined that the facility did not have an on-call physician available for services that are provided (Orthopedic Surgery, Plastic Surgery and Hand Surgery).

Findings include:

Reference: Facility Medical Staff Rules and Regulations state, "...Call Schedule
An on-call list of physicians available to examine and provide treatment necessary to stabilize individuals with an emergency medical condition shall be established and posted on the [Health Care System] intranet for every specialty of the Medical Staff for which there are sufficient number of active attending physicians..."

1. On 11/17/2020, a review of the on-call physician calendars from May 2020 to November 2020 for Orthopedic Surgery was completed and the following was identified:

a. For July 2020, the following dates did not have a physician on-call at the facility: 7/2, 7/3, and 7/4.

(i) There was a listed phone number to call on the above dates. An interview with Staff #19 on 11/17/2020 at 1:44 PM revealed that the number was to the health systems transfer center and not to a direct physician that would be on-call.

2. On 11/17/2020, a review of the on-call physician calendars from May 2020 to November 2020 for Plastic Surgery was completed and the following was identified:

a. For May 2020, the following dates did not have a physician on-call at the facility: 5/1, 5/5, 5/6, 5/7, 5/8, 5/9, 5/13, 5/14, 5/15, 5/18, 5/21, 5/22, 5/28, 5/29, and 5/30.

b. For June 2020, the following dates did not have a physician on-call at the facility: 6/1, 6/4, 6/5, 6/11, 6/12, 6/14, 6/15, 6/18, 6/19, 6/22, 6/25, 6/26, and 6/30.

c. For July 2020, the following dates did not have a physician on-call at the facility: 7/2, 7/3, 7/4, 7/5, 7/6, 7/9, 7/10, 7/13, 7/16, 7/17, 7/23, 7/24, 7/30, and 7/31.

d. For August 2020, the following dates did not have a physician on-call at the facility: 8/6, 8/7, 8/12, 8/13, 8/14, 8/15, 8/16, 8/17, 8/18, 8/19, 8/20, 8/21, 8/22, 8/23, 8/24, 8/27, and 8/28.

e. For September 2020, the following dates did not have a physician on-call at the facility: 9/3, 9/4, 9/10, 9/11, 9/14, 9/17, 9/18, 9/21, 9/24, and 9/25.

f. For October 2020, the following dates did not have a physician on-call at the facility: 10/1, 10/2, 10/8, 10/9, 10/15, 10/16, 10/19, 10/22, 10/23, 10/25, 10/29, 10/30, and 10/31.

g. For November 2020, the following dates did not have a physician on-call at the facility: 11/3, 11/5, 11/6, 11/12, 11/13, 11/16, 11/19, 11/20, 11/25, 11/26, and 11/27.

3. An interview with Staff #19 on 11/17/2020 at 1:44 PM revealed that there is only one physician at the facility available to take call for Plastic Surgery, and therefore that physician would not be scheduled every day.

4. On 11/17/2020, a review of the on-call physician calendars from May 2020 to November 2020 for Hand Surgery was completed and the following was identified:

a. For May 2020, the following dates did not have a physician on-call at the facility: 5/1, 5/5, 5/6, 5/7, 5/8, 5/9, 5/13, 5/14, 5/15, 5/18, 5/21, 5/22, 5/28, 5/29, and 5/30.

b. For June 2020, the following dates did not have a physician on-call at the facility: 6/1, 6/4, 6/5, 6/11, 6/12, 6/14, 6/15, 6/18, 6/19, 6/22, 6/25, 6/26, and 6/30.

c. For July 2020, the following dates did not have a physician on-call at the facility: 7/2, 7/3, 7/4, 7/5, 7/6, 7/9, 7/10, 7/13, 7/16, 7/17, 7/23, 7/24, 7/30, and 7/31.

d. For August 2020, the following dates did not have a physician on-call at the facility: 8/6, 8/7, 8/12, 8/13, 8/14, 8/15, 8/16, 8/17, 8/18, 8/19, 8/20, 8/21, 8/22, 8/23, 8/24, 8/27, and 8/28.

e. For September 2020, the following dates did not have a physician on-call at the facility: 9/3, 9/4, 9/10, 9/11, 9/14, 9/17, 9/18, 9/21, 9/24, and 9/25.

f. For October 2020, the following dates did not have a physician on-call at the facility: 10/1, 10/2, 10/8, 10/9, 10/15, 10/16, 10/19, 10/22, 10/23, 10/25, 10/29, 10/30, and 10/31.

g. For November 2020, the following dates did not have a physician on-call at the facility: 11/3, 11/5, 11/6, 11/12, 11/13, 11/16, 11/19, 11/20, 11/25, 11/26, and 11/27.

h. There was a listed phone number to call on the above dates. An interview with Staff #19 on 11/17/2020 at 1:44 PM revealed that the number was to the health systems transfer center and not to a direct physician that would be on-call.

5. An interview with Staff #19 on 11/17/2020 at 1:44 PM stated that if a day was left blank or did not identify a specific physician on-call, then if a patient presented to the facility ED needing a specialty service, the patient would be transferred out.

B. Based on staff interview, document review, and review of the facility's medical staff rules and regulations, it was determined that the facility failed to ensure policies are in place in the event that a particular specialty is not available.

Findings include:

Reference: Facility Medical Staff Rules and Regulations state, "...Call Schedule An on-call list of physicians available to examine and provide treatment necessary to stabilize individuals with an emergency medical condition shall be established and posted on the [Health Care System] intranet for every specialty of the Medical Staff for which there are sufficient number of active attending physicians... On-Call Responsibilities ...If no specialist physician is available to deliver care to the Emergency Department patient, the patient will be transferred to another institution..."

1. On 11/17/2020, a review of the on-call physician calendars from May 2020 to November 2020 for Orthopedic Surgery was completed and the following was identified:

a. For July 2020, the following dates did not have a physician on-call at the facility: 7/2, 7/3, and 7/4.

(i) There was a listed phone number to call on the above dates. An interview with Staff #19 on 11/17/2020 at 1:44 PM revealed that the number was to the health systems transfer center and not to a direct physician that would be on-call.

2. On 11/17/2020, a review of the on-call physician calendars from May 2020 to November 2020 for Plastic Surgery was completed and the following was identified:

a. For May 2020, the following dates did not have a physician on-call at the facility: 5/1, 5/5, 5/6, 5/7, 5/8, 5/9, 5/13, 5/14, 5/15, 5/18, 5/21, 5/22, 5/28, 5/29, and 5/30.

b. For June 2020, the following dates did not have a physician on-call at the facility: 6/1, 6/4, 6/5, 6/11, 6/12, 6/14, 6/15, 6/18, 6/19, 6/22, 6/25, 6/26, and 6/30.

c. For July 2020, the following dates did not have a physician on-call at the facility: 7/2, 7/3, 7/4, 7/5, 7/6, 7/9, 7/10, 7/13, 7/16, 7/17, 7/23, 7/24, 7/30, and 7/31.

d. For August 2020, the following dates did not have a physician on-call at the facility: 8/6, 8/7, 8/12, 8/13, 8/14, 8/15, 8/16, 8/17, 8/18, 8/19, 8/20, 8/21, 8/22, 8/23, 8/24, 8/27, and 8/28.

e. For September 2020, the following dates did not have a physician on-call at the facility: 9/3, 9/4, 9/10, 9/11, 9/14, 9/17, 9/18, 9/21, 9/24, and 9/25.

f. For October 2020, the following dates did not have a physician on-call at the facility: 10/1, 10/2, 10/8, 10/9, 10/15, 10/16, 10/19, 10/22, 10/23, 10/25, 10/29, 10/30, and 10/31.

g. For November 2020, the following dates did not have a physician on-call at the facility: 11/3, 11/5, 11/6, 11/12, 11/13, 11/16, 11/19, 11/20, 11/25, 11/26, and 11/27.

3. An interview with Staff #19 on 11/17/2020 at 1:44 PM revealed that there is only one physician at the facility available to take call for Plastic Surgery, and therefore that physician would not be scheduled every day.

4. On 11/17/2020, a review of the on-call physician calendars from May 2020 to November 2020 for Hand Surgery was completed and the following was identified:

a. For May 2020, the following dates did not have a physician on-call at the facility: 5/1, 5/5, 5/6, 5/7, 5/8, 5/9, 5/13, 5/14, 5/15, 5/18, 5/21, 5/22, 5/28, 5/29, and 5/30.

b. For June 2020, the following dates did not have a physician on-call at the facility: 6/1, 6/4, 6/5, 6/11, 6/12, 6/14, 6/15, 6/18, 6/19, 6/22, 6/25, 6/26, and 6/30.

c. For July 2020, the following dates did not have a physician on-call at the facility: 7/2, 7/3, 7/4, 7/5, 7/6, 7/9, 7/10, 7/13, 7/16, 7/17, 7/23, 7/24, 7/30, and 7/31.

d. For August 2020, the following dates did not have a physician on-call at the facility: 8/6, 8/7, 8/12, 8/13, 8/14, 8/15, 8/16, 8/17, 8/18, 8/19, 8/20, 8/21, 8/22, 8/23, 8/24, 8/27, and 8/28.

e. For September 2020, the following dates did not have a physician on-call at the facility: 9/3, 9/4, 9/10, 9/11, 9/14, 9/17, 9/18, 9/21, 9/24, and 9/25.

f. For October 2020, the following dates did not have a physician on-call at the facility: 10/1, 10/2, 10/8, 10/9, 10/15, 10/16, 10/19, 10/22, 10/23, 10/25, 10/29, 10/30, and 10/31.

g. For November 2020, the following dates did not have a physician on-call at the facility: 11/3, 11/5, 11/6, 11/12, 11/13, 11/16, 11/19, 11/20, 11/25, 11/26, and 11/27.

h. There was a listed phone number to call on the above dates. An interview with Staff #19 on 11/17/2020 at 1:44 PM revealed that the number was to the health systems transfer center and not to a direct physician that would be on-call.

5. An interview with Staff #19 on 11/17/2020 at 1:44 PM identified that if a day was left blank or did not identified a specific physician on-call, then if a patient present to the facility ED needing a specialty service, the patient would be transferred out.

6. During a tour of the ED on 11/16/2020, and interview was conducted with Staff #7 at 12:05 PM that identified if a there was no physician on-call for the facility that the procedure is to call a different facility within the health care system to see if there was a physician on-call there. If a physician was on-call within the health care system, then that physician would be asked if they were available to do a consult.

7. In 11/18/2020, the meeting minutes from the Department of Emergency Medicine Joint meeting between the facility and a nearby health system facility dated 8/18/2020 was reviewed, and the following was identified: The section titled, "New Business" identified to "...Try to use local Physicians first before transfer... if not on call here maybe at [facility]."

8. Upon request, the facility was unable to provide evidence of the on-call policy that provided guidelines for ED staff to call other facilities first before transfer when a particular specialty is not available. Staff #3, Staff #19, and Staff #27 confirmed on 11/18/2020 at 12:58 PM that there are no policies that delineate the protocol for identifying on-call staff when the on-call is not available at the facility.

Based on staff interview, review of policy and procedure, and the review of five (5) medical records of patients transferred to another facility, it was determined that the facility failed to ensure that the physician certification for consent was completed at the time of transfer in four (4) out of five (5) medical records (#12, #14, #25, #26).

Findings include:

Reference #1: Policy titled, "Disposition and Discharge Procedure" states, "...B. TRANSFER: ...3. Transfer paperwork will be completed and copies of all medical records will be sent with the patient to complete an Appropriate Transfer of the patient....."

Reference #2: Policy titled, "Emergency Care & Transfers of Individuals with Emergency Medical Conditions (EMTALA)" states, "...Procedure: ...9. An individual who has not been stabilized may be appropriately transferred from the [Health System Facility] to another facility in accordance with the conditions set forth... only if either of the following criteria are met: ...A physician has signed a certification that [sic] based on the information available at the time of transfer; the medical benefits reasonably expected from appropriate medical treatment at another medical facility outweigh the increased risks to the individual..."


43214


1. On 11/17/2020, a review of Medical Record #12 revealed the following:

a. The patient arrived to the Emergency Department (ED) on 6/21/2020 at 5:37 AM for a psychiatric evaluation due to Suicidal Ideations. The patient was transferred to another facility for treatment at 9:41 PM.

b. A "Physician Certification Consent for Transfer" form was not found in the patient's medical record.

c. On 11/18/2020 at 12:02 PM, an interview with Staff #3 and Staff #27 confirmed the above findings.

2. The medical record of Patient #14 was reviewed on 11/18/2020, and the following was identified:

a. Patient #14 arrived at the ED on 7/27/2020 at 8:08 AM with a complaint of pain in the right leg. The patient was transferred to another facility for treatment on 7/27/2020 at 1:04 PM.

b. A "Physician Certification Consent for Transfer" form, dated and timed 7/27/2020 at 11:23 AM, was incomplete in the following sections:

(i) "Name of Physician Certifying Transfer"

(ii) "Reason for Transfer"

(iii) "SECTION 1 Patient Condition"

3. Review of Medical Record #25 on 11/18/2020, revealed the following:

a. The patient arrived at the ED on 10/22/2020 at 5:20 PM with arm pain. The patient was transferred to another facility for treatment at 10:04 PM.

b. A "Physician Certification Consent for Transfer" form dated 10/22/2020 was incomplete, with the following sections left blank:

(i) "Name of Physician Certifying Transfer"

(ii) "Reason for Transfer"

(iii) "Benefits Explanation"

(iv) "Risks Explanation"

c. A "Physician's Transfer Orders" form, dated 10/22/2020 was incomplete, with the following sections left blank:

(i) "Bed Assignment"

(ii) "Contact Phone # [number]"

(iii) "Person Spoken to at Receiving Facility"

4. On 11/18/2020, a review of Medical Record #26 revealed the following:

a. The patient arrived at the ED on 11/7/2020 at 11:54 AM, with right-sided facial droop and seizure. The patient was transferred to another facility for treatment at 2:29 PM.

b. A "Physician Certification Consent for Transfer" form dated 11/7/2020 was incomplete, with the following sections left blank:

(i) "Patient Condition"

(ii) "Reason for Transfer"

(iii) "Benefits Explanation"

5. The above findings were confirmed with Staff #1, Staff #3 and Staff #27 on 11/18/2020 at 1:20 PM.