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Based on staff interviews and review of medical records, policies/procedures and Medical Staff Bylaws, the facility failed to comply with the Medicare provider agreement as defined in ?489.20 and ?489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

Findings:

1. The facility failed to meet the following requirement under the EMTALA regulations:

Tag A 2402 - Posting of Signs
The facility failed to post signage visual to all individuals entering the emergency department that specifies the rights of individuals with respect to examination and treatment of emergency medical conditions, as well as whether the facility participates in the Medicaid program under a State approved plan.

Tag A 2405 - Emergency Room Log
The hospital failed to ensure that the Emergency Department (ED) and Obstetrics Department (OB) logs were accurate, complete and contained all of the required information, including whether the patient refused treatment, was refused treatment, was evaluated/treated, and admitted, transferred, discharged or expired.

A 2409 - Appropriate Transfer:
The transferring hospital failed to include in the transfer paperwork some/all of the following required information: the reason for transfer, name of receiving facility, risks and benefits of the transfer and stability of the emergency medical condition at the time of transfer.

Based on tours/observations and staff interview and review of facility documents, the facility failed to post signage visual to all individuals entering the emergency department that specifies the rights of individuals with respect to examination and treatment of emergency medical conditions, as well as whether the facility participates in the Medicaid program under a State approved plan.
Findings:
1. The facility failed to adequately post EMTALA (Emergency Medical Treatment and Active Labor Act) signage, as required, throughout the main campus ED and in a freestanding ED located in another community.

a) Tour/observations conducted at the facility's freestanding Emergency Department, located in another community, on 02/19/13 at 10:30 a.m. with the Director of the freestanding ED, the facility Compliance Officer, the facility Chief Nursing Officer (interim), the facility Chief Operating Officer and the Medical Director of the freestanding ED revealed that there was one set of signs in the lobby near the registration desk but no sign posted in the ambulance bay or inside ambulance bay door or anywhere else in the Emergency Department to be viewed by individuals who did not enter through the lobby. These findings were confirmed with the facility staff present on the tour.

b) Observations conducted at the main campus on 02/20/13 at approximately 1:30 p.m., with the Chief Operating Officer, the Compliance Officer and Director of the Emergency Department, who was also the Interim Chief Nursing Officer for the facility, revealed that there was no EMTALA signage posted at the rooftop helipad entrance to the building and the direct elevator from the rooftop helipad to the Emergency Department. In addition, there were no signs in the trauma rooms, to which the patients transported by helicopter were most likely to be taken for treatment. These findings were confirmed with the facility staff present on the tour.

c) Review on 02/19/13 of the facility policy/procedure entitled " EMTALA - Definitions and General Requirements," revealed the following, in part:
"DEFINITIONS:
Signage refers to the legal requirements of the (Facility name) to post signs conspicuously in any of its emergency departments or in a place or places likely to be noticed by all individuals entering the emergency department as well as those individuals waiting for examination and treatment in areas other than the traditional emergency department, (e.g., labor and delivery, waiting room, admitting area, entrance and treatment areas) informing the patients of their rights under federal law with respect to examination and treatment for Emergency Medical Conditions and women in labor."

Based on document review and interviews, the facility failed to maintain a central log, of all patients who presented to the Emergency Department, which clearly reflected all information required by the regulation.

The failure created the potential for the facility to have incomplete and/or incorrect information regarding patients who were seen in the Emergency Department and by the Obstetrics Department.

FINDINGS:

1. The facility did not maintain a central log that was complete, correct, reflected patients' status after being seen in the Emergency Department and/or by Obstetrics, and was easily produced by facility staff.

a) On 02/18/13 at 9:35 a.m., an entrance conference meeting was held with the facility's Chief Operating Officer (COO) and interim Chief Nursing Officer (CNO). The central log for the facility's Emergency Department (ED) was requested for the main site, as well as the off site ED, for July, 2012 to 02/18/13. The CNO stated the log was maintained in electronic format. The central log for patients entering the ED/facility in need of obstetrics (OB) care was also requested for July, 2012 through 02/18/13. The CNO stated these logs were maintained on paper/hardcopy.

b) On 02/18/13 at 11:20 a.m., the central logs were requested a second time from the facility's COO.

c) On 02/18/13 at 12:10 p.m., surveyors received the OB paper/hardcopy logs requested. The CNO stated the electronic ED logs were not yet available.

d) On 02/18/13 at 1:30 p.m., the ED central logs were received by surveyors, approximately 4 hours after first requested.

e) On 02/28/13 at 1:30 p.m., the central logs were reviewed by surveyors. The logs contained categories that did not give a clear indication of patients' status after being seen in the ED or in OB. These categories were, "discharge/transfer," "other/discharge/transfer," "enforcement," "left with law enforcement," "facility," "patient," and "still inpatient."

f) On 02/18/13 at 2:03 p.m., an interview was conducted with the facility's CNO and the facility's Ethics/Compliance and Privacy Officer to review findings from the central logs. The Privacy Officer stated that upon review of the logs, s/he would need to review patients' medical records to understand their status after being seen in the ED or OB, as this information was not clearly indicated on the logs. When asked specifically about the category, "other/discharge/transfer," and that this category held very different meanings for patient status, the Privacy Officer stated that s/he would have to review patients' medical records in the category to understand patient status after being seen in the facility. The Privacy Officer stated different staff members input data into the electronic system, of which the central log is part, and that there were inconsistencies by these users of the system when categories were chosen regarding patient status after being seen in the ED/OB.

g) On 02/18/13 at 3:00 p.m., an interview was conducted with the facility's CNO to review obstetric patients that, per the log, were "transferred," indicating that these patients needed a higher level of care than could be provided by the facility upon arrival in the ED/OB. Review of medical records revealed that some patients were transferred from the facility to other facilities, for different reasons, days after being admitted which was not a transfer per EMTALA regulations but simply a transfer from one facility to another after being admitted. The CNO confirmed that on the OB log, some "transfers" were not actually transfers per EMTALA regulations, and that the log should be changed to ensure that transfers, per the regulations, were made part of the log.

h) On 02/19/13 at 2:50 p.m., facility policies were reviewed. The policy titled, "EMTALA-Central Log," dated 07/12, revealed the facility would maintain a central log to include whether patients, "left before a medical screening examination ("MSE") could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged." The policy stated the central log, "must be available in a timely manner for surveyor review." The policy titled, "EMTALA-Definitions and General Requirements," dated 10/12, stated, "The purpose of the central log is to track the care provided to each patient who comes to [the facility] seeking care for an emergency medical condition."

i) On 02/20/13 at 3:12 p.m., an interview was conducted with the facility's Privacy Officer and CNO who confirmed the verbiage found in facility policies regarding maintaining a central log of patients who present to the facility's Emergency Department. The Privacy Officer and CNO agreed that the log(s) presented to surveyors did not meet the regulation requirements.

Based on medical record reviews, staff interviews and review of facility documents, the hospital failed to ensure that when Emergency Department (ED) or Obstetrics Department (OB) patients were transferred to another facility for specialized care or a higher level of care to treat their emergency medical conditions, the transfer paperwork contained all of the following required information: the reason for transfer, name of receiving facility, risks and benefits of the transfer and stability of the emergency medical condition at the time of transfer, as required in their policies/procedures and EMTALA regulations. The failure created the potential for negative patient outcomes.

Findings:

The ED and OB staff failed include all of the required information, including the name of the receiving facility, specific reason for transfer, risks and benefits of the transfer, and stability of the patient's emergency medical condition at the time of transfer and condition of the patient at the time of transfer on the transfer, on the 2-page transfer form utilized by the facility in 8 of 10 sample patients transferred from the facility.

a) Review on 02/19/13 of the facility policy/procedure entitled : "EMTALA - Emergency Patient Transfers," revealed the following, in part:
"PROCEDURE::
1. REQUIREMENTS FOR ALL TRANSFERS OF INDIVIDUALS WHO ARE NOT MEDICALLY STABILIZED
After the hospital has provided medical treatment within its capability to minimize the risks to the health of an individual with an EMC (Emergency Medical Condition), who is not medically stable, the hospital may arrange an appropriate transfer for the individual to another more appropriate or specialized facility. For any transfer of an individual with and EMC that has not been stabilized, all of the following circumstances must be met:

E. Send Medical Records
- The individual's vital signs which should be taken immediately prior to transfer and documented on EMTALA TRANSFER FORM found in (facility name) EMTALA transfer Packet.

F. Physician Certification of Risks and Benefits
A physician must sign an express written certification that based on the information available at the time of transfer the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the unborn child, from being transferred. The certification should meet the following requirements:
- The certification should be specific to the condition of the patient upon transfer.
- The certification must contain a complete picture of the benefits to be expected from appropriate care at the receiving facility as well as a summary of the material risks associated with the transfer, including the time away from an acute care setting necessary to affect the transfer.
- The certification must state the reason(s) for transfer. This rationale may be documented on the certification form or elsewhere in the medical record.
- The date and time of the physician certification should closely match the date and time of the transfer."

b) Review of the medical record for sample patient #5 revealed that the patient was an obstetric patient that was transferred emergently to a hospital with a higher level of obstetric/neonatal care, although the specific rationale for the transfer and the risks and benefits of the transfer were not clearly described in the 2-page "EMTALA TRANSFER FORM " or anywhere else in the patient record. The only explanation for the transfer was a statement in the Transfer/Discharge Summary which stated that the obstetrician had consulted with a neonatologist at the other hospital in town and that s/he had recommended that the patient be sent to the receiving hospital (a university medical center), in another city, for care.

c) Review of the medical record for sample patient #11 revealed that the patient was an adult patient with abdominal pain, elevated cardiac enzymes and irregular EKG with a cardiac history. The patient was transferred from the freestanding ED in another community to another acute care hospital in that community. Other than a statement in the dictated Emergency Room Record that the patient was going to be accepted by a hospitalist in the receiving hospital and would be on telemetry, the Physician Certification /EMTALA TRANSFER FORM contained no clear statement of the rationale for transfer and or the risks and benefits of transfer, as required.

d) Review of the medical record for sample patient #14 revealed the patient presented to the Emergency Department (ED) with a gunshot wound to the upper thigh. The patient was in the ED for approximately 1.5 hours, received pain medication and his/her leg was splinted. The EMTALA transfer form revealed the name of the receiving facility was left blank, no risk of transfer or mode of transfer was indicated, and the patient did not sign the consent to be transferred. There was no documentation on the transfer form, or in the medical record, that the patient was unable to sign the consent or that the patient agreed to the transfer. The section of the transfer form indicating that the facility provided treatment within its capacity, and that the facility receiving the patient had space and qualified personnel to provide care for the patient, was also left blank.

e) Review of the medical record for sample patient #15 revealed the patient presented to the ED with altered speech and difficulty walking. The patient was stabilized, per the physician's dictated report, and transferred to another facility. The EMTALA transfer form revealed the benefit of transfer as, "bed capacity not currently available," and no specific medical benefit to the patient was documented by the certifying physician. The risk of transfer was documented as "transportation risk" with no specific medical risk documented by the certifying physician.

f) Review of the medical record for sample patient #16 revealed the patient presented to the ED with chest pain and was transferred to another facility after approximately 4.5 hours. The EMTALA transfer form revealed the name of the receiving facility was left blank, and specific benefits and risks to the patient of transfer were not documented by the certifying physician.

g) Review of the medical record for sample patient #17 revealed the patient presented to the ED with chest pain and was transferred to another facility after approximately 3 hours. The EMTALA transfer form revealed the name of the receiving facility was left blank, the benefit of transfer was documented as, "bed capacity not currently available," and no specific medical benefit to the patient was documented by the certifying physician. The risk of transfer was documented as "transportation risk" with no specific medical risk documented by the certifying physician. The section of the transfer form indicating that the facility provided treatment within its capacity, and that the facility receiving the patient had space and qualified personnel to provide care for the patient, was left blank.

h) Review of the medical record for sample patient #18 revealed the patient presented to the ED at 40 weeks of pregnancy. The EMTALA transfer form revealed the benefit of transfer as, "bed capacity not currently available," and no specific medical benefit to the patient was documented by the certifying physician. The risk of transfer was documented as "transportation risk" with no specific medical risk documented by the certifying physician.

i) Review of the medical record for sample patient #22 revealed the patient presented to the ED with wheezing/respiratory illness, was observed for approximately 3.5 hours, was given two Albuterol treatments, and per the physician's dictated report, remained tachypneic at the time of transfer to another facility. The section of the transfer form indicating that the facility provided treatment within its capacity, and that the facility receiving the patient had space and qualified personnel to provide care for the patient, was left blank.

j) On 02/20/13 at 3:01 p.m., an interview was conducted with the facility's interim Chief Nursing Officer (CNO) and the facility's Ethics/Compliance and Privacy Officer to review findings from patient medical record review related to documentation of transferred patients. Both staff members confirmed the findings documented above, and agreed that issues were present related to the completeness and accuracy of the EMTALA transfer forms.