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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement, as defined in §489.24, related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

FINDINGS:

1. The facility failed to meet the following requirements under the EMTALA regulation:

Tag A2405 - Emergency Room Log

Based on interviews and document review, the facility failed to maintain a centralized log that contained accurate information and allowed the facility to track the care provided for patients who presented to the facility for emergency services. Specifically, pediatric patients who presented to the adult emergency department (ED) seeking emergency medical care were transferred to the pediatric emergency department. The facility failed to maintain a centralized log which tracked and reflected the accurate time pediatric patients arrived at the facility seeking emergency treatment for 8 of 8 pediatric records reviewed for pediatric patients who presented to the adult ED (Patients #1, #6, #7, #8, #9, #10, #11, and #23). This failure resulted in the facility not being able to track patients' emergency care from the point when the patient initially arrived at the facility's adult Emergency Department (ED) seeking emergency treatment to when the patient arrived at the pediatric ED.

Based on interviews and document review, the facility failed to maintain a centralized log that contained accurate information and allowed the facility to track the care provided for patients who presented to the facility for emergency services. Specifically, pediatric patients who presented to the adult emergency department (ED) seeking emergency medical care were transferred to the pediatric emergency department. The facility failed to maintain a centralized log which tracked and reflected the accurate time pediatric patients arrived at the facility seeking emergency treatment for 8 of 8 pediatric records reviewed for pediatric patients who presented to the adult ED (Patients #1, #6, #7, #8, #9, #10, #11, and #23).

This failure resulted in the facility not being able to track patients' emergency care from the point when the patient initially arrived at the facility's adult Emergency Department (ED) seeking emergency treatment to when the patient arrived at the pediatric ED.

FINDINGS:

1. The facility failed to maintain a complete and accurate central log of pediatric patients who presented to the adult ED.

a) Review of the Patient Through Put Flow Chart, for pediatric patients who arrived to the adult ED, revealed the patient was to receive a "triage and assessment" by an adult ED Registered Nurse (RN) or Emergency Medical Technician (EMT). Based on the assessment, the adult ED Physician or Physician's Assistant (PA) would perform a medical screening exam (MSE) if the pediatric patient was unstable. If the patient was "stable to transfer" they would be transferred to the pediatric ED

b) On 09/13/16 at 9:10 a.m., an interview was conducted with Emergency Medical Technician #4 (EMT) who stated s/he did not enter pediatric patients in the computer system when they first presented to the adult ED. EMT #4 stated s/he would fill out the pediatric assessment form, obtain the patient's vital signs, and fill out the assessment list. EMT #4 stated a Registered Nurse (RN) would review the form and then determine if the pediatric patient would stay at the adult ED or transfer to the pediatric ED. EMT #4 stated the purpose of the quick evaluation was to determine if the patient should stay or go to go to the pediatric ED. When asked if there was a way to know what time the patient presented to the facility's adult ED for emergency treatment; s/he stated there was not a way to determine the time. S/he stated there was not a way to confirm the RN assessed the patient or what time the patient arrived by looking at the form.

c) Review of the Pediatric Quick Screen forms, dated 05/01/16 through 09/12/16 and used to track pediatric patients who presented to the adult ED, showed no evidence a RN reviewed the form, evaluated the patient, and determined the pediatric patient was stable to be transferred to the pediatric ED. Additionally, there was no documentation as to what time the patient presented to the Adult ED for treatment.

d) Medical record review showed the central log failed to accurately track the care provided to pediatric patients who presented to the adult ED.

i) Review of the central log showed pediatric Patient #1 arrived on 08/15/16 at 10:13 a.m. with altered mental status. This time indicated when the patient arrived at the pediatric ED.

However, review of Patient #1's medical record showed an emergency note, documented by RN #6 at 10:45, which stated the patient was brought over from the adult ED. According to the note, upon arrival to the pediatric ED, the patient was pale, pupils noted to be pin point, heart rate was 80, minimal response, and unable to answer any questions. Review of the medication administration record, at 10:25 a.m., showed Patient #1 was administered intravenous Narcan, a drug to treat narcotic overdose in an emergency situation.

Review of the medical record showed the patient presented to the pediatric ED on 08/15/16 at 10:13 a.m. and was triaged at 10:15 a.m. RN #10 documented the parent of the child (POC) felt uncomfortable taking the patient home after being discharged a short time earlier from another facility after surgery. The POC noticed as s/he placed the patient in his/her car that the child was unresponsive and diaphoretic and decided not to take the patient home. According to the RN's assessment during the pediatric ED triage, the patient was responsive only to pain, diaphoretic and pale. The patient was four years old.

Review of Patient #1's Pediatric Quick Screen form, dated incorrectly as 08/16/16, showed no documentation of the patient's arrival time at the adult ED. The screening tool showed the patient was brought in to the adult ED for "post-op diaphoretic".

This failure resulted in an inaccurate centralized log and did not allow the facility to track the pediatric patients' care once s/he presented with an emergent medical condition to determine if treatment was timely or delayed.

ii) Review of the central log showed pediatric Patient #6 presented to the facility on 08/22/16 at 11:42 p.m. for syncope, a temporary loss of consciousness. This time indicated when the patient arrived at the pediatric ED after being brought over by adult ED personal.

Review of the Pediatric Quick Screen, completed by the adult ED, did not show the time Patient #6 arrived in the adult ED requesting emergency treatment. There was no documentation the patient's vital signs were assessed or that the patient was assessed by a RN prior to being directed to the pediatric ED. The only information documented on the form was the patient's name, date of birth, and chief complaint.

Patient #6's medical record showed the pediatric patient was admitted on 08/22/16 to the pediatric ED at 11:42 p.m. for syncope. There was no evidence in the medical record showing the time the pediatric patient presented to the adult ED for emergency care and that s/he was assessed and triaged by nursing staff prior to being transferred to the pediatric ED.

On 09/12/16 at 3:21 p.m., an interview was conducted with Director #1 who reviewed Patient #6's medical record and the Pediatric Quick Screen. Director #1 stated there was no way to know whether an EMT or RN completed the form. Director #1 further stated there was no way to know what time the patient initially presented to the Adult ED for emergency care and that the patient was assessed prior to transfer by reviewing the form.

Director #1 stated previously, the patient's arrival time was entered in the computer when the pediatric patient presented to the Adult ED. Director #1 stated the processed changed as pediatric physicians were concerned because it could show up to a 20-minute delay during transit from the Adult ED to the Pediatric ED. Director #1 stated the Pediatric Quick Screen was not considered part of the patient's medical record.

Similar findings were found for Patients #7, #8, #9, #10, #11, and #23 in which the centralized log only reflected the arrival time the patients presented to the Pediatric ED, not the actual time when the patient presented to the facility for emergency treatment.

e) On 09/14/16 at 3:09 p.m., an interview was conducted with Director #5 who stated s/he reviewed the Pediatric Quick Screen form to track percentage of pediatric patients who presented to the ED. Director #5 stated s/he was the one who documented the dates on the form and there was no current monitoring process ensuring the forms were completed entirely when pediatric patient presented to the Adult ED.

Based on interviews and document review, the facility failed to comply with the Medicare provider agreement, as defined in §489.24, related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

FINDINGS:

1. The facility failed to meet the following requirements under the EMTALA regulation:

Tag A2405 - Emergency Room Log

Based on interviews and document review, the facility failed to maintain a centralized log that contained accurate information and allowed the facility to track the care provided for patients who presented to the facility for emergency services. Specifically, pediatric patients who presented to the adult emergency department (ED) seeking emergency medical care were transferred to the pediatric emergency department. The facility failed to maintain a centralized log which tracked and reflected the accurate time pediatric patients arrived at the facility seeking emergency treatment for 8 of 8 pediatric records reviewed for pediatric patients who presented to the adult ED (Patients #1, #6, #7, #8, #9, #10, #11, and #23). This failure resulted in the facility not being able to track patients' emergency care from the point when the patient initially arrived at the facility's adult Emergency Department (ED) seeking emergency treatment to when the patient arrived at the pediatric ED.

Based on interviews and document review, the facility failed to maintain a centralized log that contained accurate information and allowed the facility to track the care provided for patients who presented to the facility for emergency services. Specifically, pediatric patients who presented to the adult emergency department (ED) seeking emergency medical care were transferred to the pediatric emergency department. The facility failed to maintain a centralized log which tracked and reflected the accurate time pediatric patients arrived at the facility seeking emergency treatment for 8 of 8 pediatric records reviewed for pediatric patients who presented to the adult ED (Patients #1, #6, #7, #8, #9, #10, #11, and #23).

This failure resulted in the facility not being able to track patients' emergency care from the point when the patient initially arrived at the facility's adult Emergency Department (ED) seeking emergency treatment to when the patient arrived at the pediatric ED.

FINDINGS:

1. The facility failed to maintain a complete and accurate central log of pediatric patients who presented to the adult ED.

a) Review of the Patient Through Put Flow Chart, for pediatric patients who arrived to the adult ED, revealed the patient was to receive a "triage and assessment" by an adult ED Registered Nurse (RN) or Emergency Medical Technician (EMT). Based on the assessment, the adult ED Physician or Physician's Assistant (PA) would perform a medical screening exam (MSE) if the pediatric patient was unstable. If the patient was "stable to transfer" they would be transferred to the pediatric ED

b) On 09/13/16 at 9:10 a.m., an interview was conducted with Emergency Medical Technician #4 (EMT) who stated s/he did not enter pediatric patients in the computer system when they first presented to the adult ED. EMT #4 stated s/he would fill out the pediatric assessment form, obtain the patient's vital signs, and fill out the assessment list. EMT #4 stated a Registered Nurse (RN) would review the form and then determine if the pediatric patient would stay at the adult ED or transfer to the pediatric ED. EMT #4 stated the purpose of the quick evaluation was to determine if the patient should stay or go to go to the pediatric ED. When asked if there was a way to know what time the patient presented to the facility's adult ED for emergency treatment; s/he stated there was not a way to determine the time. S/he stated there was not a way to confirm the RN assessed the patient or what time the patient arrived by looking at the form.

c) Review of the Pediatric Quick Screen forms, dated 05/01/16 through 09/12/16 and used to track pediatric patients who presented to the adult ED, showed no evidence a RN reviewed the form, evaluated the patient, and determined the pediatric patient was stable to be transferred to the pediatric ED. Additionally, there was no documentation as to what time the patient presented to the Adult ED for treatment.

d) Medical record review showed the central log failed to accurately track the care provided to pediatric patients who presented to the adult ED.

i) Review of the central log showed pediatric Patient #1 arrived on 08/15/16 at 10:13 a.m. with altered mental status. This time indicated when the patient arrived at the pediatric ED.

However, review of Patient #1's medical record showed an emergency note, documented by RN #6 at 10:45, which stated the patient was brought over from the adult ED. According to the note, upon arrival to the pediatric ED, the patient was pale, pupils noted to be pin point, heart rate was 80, minimal response, and unable to answer any questions. Review of the medication administration record, at 10:25 a.m., showed Patient #1 was administered intravenous Narcan, a drug to treat narcotic overdose in an emergency situation.

Review of the medical record showed the patient presented to the pediatric ED on 08/15/16 at 10:13 a.m. and was triaged at 10:15 a.m. RN #10 documented the parent of the child (POC) felt uncomfortable taking the patient home after being discharged a short time earlier from another facility after surgery. The POC noticed as s/he placed the patient in his/her car that the child was unresponsive and diaphoretic and decided not to take the patient home. According to the RN's assessment during the pediatric ED triage, the patient was responsive only to pain, diaphoretic and pale. The patient was four years old.

Review of Patient #1's Pediatric Quick Screen form, dated incorrectly as 08/16/16, showed no documentation of the patient's arrival time at the adult ED. The screening tool showed the patient was brought in to the adult ED for "post-op diaphoretic".

This failure resulted in an inaccurate centralized log and did not allow the facility to track the pediatric patients' care once s/he presented with an emergent medical condition to determine if treatment was timely or delayed.

ii) Review of the central log showed pediatric Patient #6 presented to the facility on 08/22/16 at 11:42 p.m. for syncope, a temporary loss of consciousness. This time indicated when the patient arrived at the pediatric ED after being brought over by adult ED personal.

Review of the Pediatric Quick Screen, completed by the adult ED, did not show the time Patient #6 arrived in the adult ED requesting emergency treatment. There was no documentation the patient's vital signs were assessed or that the patient was assessed by a RN prior to being directed to the pediatric ED. The only information documented on the form was the patient's name, date of birth, and chief complaint.

Patient #6's medical record showed the pediatric patient was admitted on 08/22/16 to the pediatric ED at 11:42 p.m. for syncope. There was no evidence in the medical record showing the time the pediatric patient presented to the adult ED for emergency care and that s/he was assessed and triaged by nursing staff prior to being transferred to the pediatric ED.

On 09/12/16 at 3:21 p.m., an interview was conducted with Director #1 who reviewed Patient #6's medical record and the Pediatric Quick Screen. Director #1 stated there was no way to know whether an EMT or RN completed the form. Director #1 further stated there was no way to know what time the patient initially presented to the Adult ED for emergency care and that the patient was assessed prior to transfer by reviewing the form.

Director #1 stated previously, the patient's arrival time was entered in the computer when the pediatric patient presented to the Adult ED. Director #1 stated the processed changed as pediatric physicians were concerned because it could show up to a 20-minute delay during transit from the Adult ED to the Pediatric ED. Director #1 stated the Pediatric Quick Screen was not considered part of the patient's medical record.

Similar findings were found for Patients #7, #8, #9, #10, #11, and #23 in which the centralized log only reflected the arrival time the patients presented to the Pediatric ED, not the actual time when the patient presented to the facility for emergency treatment.

e) On 09/14/16 at 3:09 p.m., an interview was conducted with Director #5 who stated s/he reviewed the Pediatric Quick Screen form to track percentage of pediatric patients who presented to the ED. Director #5 stated s/he was the one who documented the dates on the form and there was no current monitoring process ensuring the forms were completed entirely when pediatric patient presented to the Adult ED.