HospitalInspections.org

Based on review of recorded video footage, interviews, review of medical record and central log documentation for 11 of 20 patients who presented to the hospital's ED (Patients 1, 2, 6, 7, 8, 12, 13, 16, 17, 18 and 20), and review of hospital policies, procedures, and other documents, it was determined the hospital failed to enforce its EMTALA policies and procedures in the following areas:
* MSEs;
* Appropriate transfers of patients; and
* Maintenance of a central ED log.

Findings included:

1. Medical Screening Examination: Refer to the findings identified under Tag A2406, CFR 489.24(a) and (c) which reflects the hospital's failure to enforce its EMTALA policies and procedures related to the provision of a MSE for Patient 1.

2. Appropriate Transfers: Refer to the findings identified under Tag A2409, CFR 489.24(e)(1-2), which reflects the hospital's failure to enforce its EMTALA policies and procedures related to appropriate transfers.

3. Central Log: Refer to the findings identified under Tag A2405, CFR 489.20(r)(3) which reflects the hospital's failure to enforce its EMTALA policies and procedures related to a central log.

Based on interview, documentation in 9 of 20 medical records reviewed of patients who presented to the hospital for a MSE (Patients 6, 7, 8, 12, 13, 16, 17, 18 and 20), review of central log documentation, and review of policies and procedures, it was determined the hospital failed to ensure it implemented its EMTALA policies and procedures to ensure the maintenance of a central log which contained complete, clear and accurate information about patients who presented to the hospital for a MSE and their disposition from the hospital.

Findings included:

1. The hospital's policy and procedure titled "EMTALA (Emergency Medical Treatment and Active Labor Act)", dated as revised "12/15" was reviewed. It reflected the following: "Central Log...The Emergency Department and Labor & Delivery Department will maintain a central log on each individual who 'comes to the emergency department' seeking services. The log will record the name of each person who presents for emergency services or obstetric evaluation and whether the person refused treatment, was refused treatment by the hospital or whether the patient was transferred, admitted and treated, stabilized and transferred, discharged, or left without being seen (LWBS) or against medical advice (AMA)...Log entries should be made in a timely manner."

2. The central log for Patient 20 reflected a discharge date and time of 08/09/2015 at 2130. The disposition and the reason for visit on the log were not completed and were blank. The record for Patient 20 reflected the patient had an "Arrival Complaint" of stomach pain and the "ED Disposition" was recorded as "None."

3. The central log for Patient 17 reflected a discharge date and time of 06/15/2015 at 0711. The disposition on the log was not completed and was blank. However, the record for Patient 17 was reviewed and RN notes recorded on 06/15/2015 at 0555 reflected "Pt deserted, [physician] notified"; and physician notes dated 06/15/2015 at 0459 reflected the disposition was "Home."

4. The central log for Patient 12 reflected a discharge date and time of 09/06/2015 at 1420. The disposition on the log was not completed and was blank. However, the record for Patient 12 reflected the patient was transferred to another hospital.

5. The central log for Patient 16 reflected a discharge date and time of 09/21/2015 at 1849. The disposition on the log was not completed and was blank. However, the record for Patient 16 reflected the patient was transferred to another hospital.

6. The central log for Patient 6 reflected a discharge date and time of 02/10/2016 at 0709. The disposition on the log was "Eloped". However, the record for Patient 6 reflected the patient was transferred to another hospital.

Similar findings were identified during the review of central log documentation and medical records for Patients 7, 8, 13 and 18.

The medical records were reviewed electronically on 02/17/2016 beginning at 1030 with numerous hospital staff including the ED Nurse Manager and Director of Accreditation, Regulation & Licensing. These findings were confirmed during interview with staff present at the time of review.

Based on review of recorded video footage, interviews, review of medical records of 1 of 3 patients who presented to the hospital's ED with law enforcement (Patient 1), review of central log documentation, and review of policies, procedures, and other documents, it was determined the hospital failed to enforce its EMTALA policies and procedures to ensure that Patient 1 was provided a MSE.

Findings included:

1. The hospital's policy and procedure titled "EMTALA (Emergency Medical Treatment and Active Labor Act)", dated as revised "12/15" was reviewed. It reflected the following: "It is the policy of the hospital to comply with the EMTALA obligations...The hospital will provide a [MSE] by a qualified medical provider to any individual who comes to the hospital seeking emergency medical treatment (or requested on their behalf); determine if the individual seeking care has an emergency medical condition (EMC); and, if an EMC exists, provide the individual with further medical examination and treatment as required to stabilize the [EMC] or arrange for transfer of the individual to another medical facility..."

The hospital's "Bylaws and Rules and Regulations of the Professional Staff", dated "September 2015" were reviewed. The section titled "Attendance of Patients in Emergency Situations" required that "An appropriate [MSE] within the capability of the hospital...shall be provided to all individuals who come to the [ED] and request (or on whose behalf a request is made) examination or treatment. Such medical screening shall be provided by qualified medical personnel."

The hospital's policy and procedure titled "Intake and Triage of the Emergency Patient at Westside Medical Center," dated as revised "07/15" was reviewed. It reflected the following: "...All patients presenting to the ED will be triaged by a [RN] and assigned an acuity number based upon their priority. The acuity is assigned using the Emergency Severity Index (ESI), and this acuity guides the prioritization of treatment. The results of the assessment must be documented and becomes a part of the patient's permanent medical record."

2. The ED central log was reviewed and reflected that Patient 1 arrived to the ED on 02/05/2016 at 1211. The "Reason for Visit" was recorded as "poh", the disposition was recorded as "[LWBS]", and the departure time was recorded as 02/05/2016 at 1225.

The ED medical record for Patient 1 reflected that the patient arrived by "Law Enforcement" in the ED on 02/05/2016 at 1211. The "Arrival Complaint" was recorded as "poh." The "Acuity" and "Escorted By" were blank.

At 1212, the CPCA recorded the patient's vital signs, height and weight; and that the patient was "roomed" in ED Triage Room B.

At 1212, the RN recorded "...DO assigned as Attending."

At 1220, the RN recorded "Went to lobby to speak with officer who brings POH. Advised officer that our hold room was RED, meaning occupied...Officer seemed comfortable with this and stated [he/she] would go to nearby [hospital]. As a newly trained ED CN I believed that this was an acceptable option. Pt and officer left the ED."

The record reflected the patient left the ED at 1225.

At 1235, the RN recorded "ED Registration does not accept the advice to remove the registration in error. Contacted the dept manager...to facilitate resolution. [Department Manager] advises to call [other hospital] and communicate the error. Information provided to me at this time to correct error. Even while in RED we still accept POH patients. This RN did not understand this and allowed [patient] to leave..."

The following sections of the record were documented as "No notes of this type exist for this encounter":
* H&P Notes
* Operative Report
* Discharge Summary

The "Pathology Results" section was documented as "No results found".

The "Diagnosis" section was documented as "None".

The "ED Disposition" was recorded "Patient left Kaiser Westside Emergency Department by Police Custody without Medical Screening Evaluation by an LIP".

There was no evidence in the medical record that the patient was triaged by an RN; and there was no evidence that the patient received a MSE in accordance with hospital policies and procedures. This was confirmed during an interview with the ED Nurse Manager on 02/17/2016 at 1030.

3. During interview with the Director of Accreditation, Regulation & Licensing on 02/16/2016 at 1440 he/she indicated that the hospital conducted an investigation of the case of Patient 1 after learning of a potential EMTALA violation involving the patient.

A document titled "Investigative Report" dated 02/12/2016 was provided by the Hospital Compliance Officer. The report reflected it was completed by the Hospital Compliance Officer. The report "Summary/Findings" reflected the following:

* "EMTALA Allegation: [Patient 1] arrived at Westside [ED] via police escort on 2/5/2016 at 12:11 pm and was registered by the [PAR]. The PAR notified...[CPCA] of the patient's arrival. [CPCA] attended to the patient and took [his/her] vitals."

* "This patient was [POH] which means the patient is in police custody and will need to be placed in a hold room...Westside ED was in 'red status' at the time of the patient's arrival - meaning that the hold room was occupied. The usual process is for the police to check this status prior to arriving. The police typically bring a POH patient through the ED back entrance, but in this case, the police arrived in the ED lobby."

* "After [CPCA] took the patient's vitals, [he/she] asked the patient to sit in the waiting area and said [he/she] would let the nurse know the patient had arrived. Knowing that [hold room] was occupied, [CPCA] said [he/she] needed to alert both the triage nurse and charge nurse."

* "[Triage Nurse] said [he/she] had a conversation with the police officer and informed [him/her] that the hold room was occupied. The police replied that if Westside ED was busy, [he/she] could go to [another hospital]."

* "[Triage Nurse] told the police that since the patient had already registered, it would be an issue if [he/she] left. [Triage Nurse] said [he/she] then notified [Charge Nurse] about the patient's arrival."

* "[Charge Nurse] said [he/she] went to talk with the police officer about 5 minutes after [Triage Nurse] notified [him/her] (about 12:30 pm). [Charge Nurse] was aware that [hold room] was occupied. [Charge Nurse] introduced [him/herself] and asked what [he/she] could do. The officer said [he/she] had a patient, but since Westside ED is on 'red status', [he/she] could take the patient to [another hospital]. [Charge Nurse] then replied, 'OK.'"

* "The officer and patient left the premises. [Charge Nurse] did not make any attempt to stop the officer and patient from leaving."

* "Other than the vitals, no other care was provided to the patient, including a medical screening exam, prior to [his/her] leaving the hospital."

* "Since the patient had been brought to the [ED] for medical treatment, the hospital had an obligation to perform a [MSE] to determine whether an [EMC] existed. This did not occur. Therefore, the allegation that EMTALA was violated is substantiated."

An interview was conducted with the Hospital Compliance Officer on 02/16/2016 at 1600. He/she confirmed the information in the investigative report involving Patient 1 above. The Compliance Officer stated that after completing the investigation, the hospital concluded that an EMTALA violation had occurred because the patient presented to the ED and no MSE was conducted.

4. Recorded video footage of Patient 1's 02/05/2016 ED visit was reviewed with the ED Nurse Manager on 02/17/2016 at 1010. The video footage was of the interior of the main ED registration and waiting area. The recording reflected the following:
* On 02/05/2016 at or around 1206 the patient and a police officer entered the ED waiting area from the direction of the ED entry.
* At or around 1215, the triage nurse approached the police officer and the patient. The patient was sitting in a chair with his/her back to the triage nurse. The triage nurse did not interact with the patient. Less than one minute later, the triage nurse left the waiting area.
* At or around 1216, the CN approached the police officer and the patient. The patient was sitting in a chair with his/her back to the CN. The CN did not interact with the patient.
* At or around 1217, the patient and the police officer walked out of the ED waiting area toward the ED entry.

There was no evidence in the video recording that reflected the patient was triaged by an RN, and there was no evidence that the patient received a MSE.

During an interview on 02/17/2016 at 1020, the ED Nurse Manager confirmed that the video recording reflected the patient was not triaged and no MSE was conducted. He/she stated "None of the nurses engaged with the patient" and "[The patient] wasn't here long enough for a medical screening exam."

Based on interview, documentation reviewed in 2 of 4 ED records of patients who presented to the hospital's ED with an EMC and who were transferred to other facilities (Patients 2 and 16), and review of hospital policies and procedures, it was determined that the hospital failed to effect all aspects of an appropriate transfers of those individuals as required by the hospital's policies and procedures. The hospital failed to ensure the required physician certification that the benefits of the transfer outweighed the increased risks of transfer. Patient specific risks of transfer were not identified for those patients.

Findings include:

1. Review of the hospital's policy titled "Transfer of Patient to Another Facility: EMTALA", dated as revised "07/15" was reviewed. It reflected the following: "...Transfers must be carried out according to the following guidelines...An individual who has a medical condition which is not stabilized may not be discharged or transferred for any reason unless one of the following conditions is met...The physician caring for the patient certifies the benefits for the transfer outweigh the risks of the transfer...Completion of the Transfer Form...When it is determined that an individual is to be transferred to another facility, the Transfer Form must be completed. All sections of the form must be completed prior to the individual being transferred...The "Physician Responsibility" section of the policy reflected "...Discuss the risk and benefit of the transfer with the individual or family member. Have the individual or family member denote if they agree or not with the transfer...Assure that all sections of the Transfer Form are completed. Certify the transfer by signing the form as the transferring physician, and date and time...Document on the transfer form the exact reason for transfer. Summarize the risks and benefits associated with transfer..."

2. The ED record for Patient 16 was reviewed. The record reflected the patient presented to the ED on 09/21/2015 at 1536. The RN notes recorded at 1609 reflected the patient's acuity was "3 [Urgent]."

The record reflected the patient received a MSE. Physician notes dated 09/21/2015 at 1617 reflected "...[Patient] presents to the [ED] complaining of [chest pain]...[chest pain] started yesterday, sharp. Pain is 8/10 at times. Comes and goes. Last pain episode w as (sic) 45min to an hr ago. Pain is mid chest, radiates to right arm. Has nausea and [shortness of breath] with it. The "Final Impression and Associated Conditions" section of the note reflected "...Acute MI" and the disposition reflected "...Transfer from WMC to [another hospital] for admission..."

The "ED Notes" documented by the RN at 1840 reflected "[Patient] transported via stretcher to [another hospital]..."

A form titled "Transfer Form" was reviewed. The top of the form reflected "All Sections Must Be Completed Prior To Transfer Of Patient." The "Physician" section of the form was signed and dated by a physician on 09/21/2015 at 1739. The "Risks of Transfer" section had a check box with an "X" in it followed by "Worsening of medical condition" and a line that was not completed and was blank. Below the blank line were the following instructions: "please specify patient specific."

There was no documentation to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks. This was confirmed during an interview with the ED Nurse Manager on 02/17/2016 at 1515.

3. Similar findings were identified during the review of the record for Patient 2.

Based on review of recorded video footage, interviews, review of medical record and central log documentation for 11 of 20 patients who presented to the hospital's ED (Patients 1, 2, 6, 7, 8, 12, 13, 16, 17, 18 and 20), and review of hospital policies, procedures, and other documents, it was determined the hospital failed to enforce its EMTALA policies and procedures in the following areas:
* MSEs;
* Appropriate transfers of patients; and
* Maintenance of a central ED log.

Findings included:

1. Medical Screening Examination: Refer to the findings identified under Tag A2406, CFR 489.24(a) and (c) which reflects the hospital's failure to enforce its EMTALA policies and procedures related to the provision of a MSE for Patient 1.

2. Appropriate Transfers: Refer to the findings identified under Tag A2409, CFR 489.24(e)(1-2), which reflects the hospital's failure to enforce its EMTALA policies and procedures related to appropriate transfers.

3. Central Log: Refer to the findings identified under Tag A2405, CFR 489.20(r)(3) which reflects the hospital's failure to enforce its EMTALA policies and procedures related to a central log.

Based on interview, documentation in 9 of 20 medical records reviewed of patients who presented to the hospital for a MSE (Patients 6, 7, 8, 12, 13, 16, 17, 18 and 20), review of central log documentation, and review of policies and procedures, it was determined the hospital failed to ensure it implemented its EMTALA policies and procedures to ensure the maintenance of a central log which contained complete, clear and accurate information about patients who presented to the hospital for a MSE and their disposition from the hospital.

Findings included:

1. The hospital's policy and procedure titled "EMTALA (Emergency Medical Treatment and Active Labor Act)", dated as revised "12/15" was reviewed. It reflected the following: "Central Log...The Emergency Department and Labor & Delivery Department will maintain a central log on each individual who 'comes to the emergency department' seeking services. The log will record the name of each person who presents for emergency services or obstetric evaluation and whether the person refused treatment, was refused treatment by the hospital or whether the patient was transferred, admitted and treated, stabilized and transferred, discharged, or left without being seen (LWBS) or against medical advice (AMA)...Log entries should be made in a timely manner."

2. The central log for Patient 20 reflected a discharge date and time of 08/09/2015 at 2130. The disposition and the reason for visit on the log were not completed and were blank. The record for Patient 20 reflected the patient had an "Arrival Complaint" of stomach pain and the "ED Disposition" was recorded as "None."

3. The central log for Patient 17 reflected a discharge date and time of 06/15/2015 at 0711. The disposition on the log was not completed and was blank. However, the record for Patient 17 was reviewed and RN notes recorded on 06/15/2015 at 0555 reflected "Pt deserted, [physician] notified"; and physician notes dated 06/15/2015 at 0459 reflected the disposition was "Home."

4. The central log for Patient 12 reflected a discharge date and time of 09/06/2015 at 1420. The disposition on the log was not completed and was blank. However, the record for Patient 12 reflected the patient was transferred to another hospital.

5. The central log for Patient 16 reflected a discharge date and time of 09/21/2015 at 1849. The disposition on the log was not completed and was blank. However, the record for Patient 16 reflected the patient was transferred to another hospital.

6. The central log for Patient 6 reflected a discharge date and time of 02/10/2016 at 0709. The disposition on the log was "Eloped". However, the record for Patient 6 reflected the patient was transferred to another hospital.

Similar findings were identified during the review of central log documentation and medical records for Patients 7, 8, 13 and 18.

The medical records were reviewed electronically on 02/17/2016 beginning at 1030 with numerous hospital staff including the ED Nurse Manager and Director of Accreditation, Regulation & Licensing. These findings were confirmed during interview with staff present at the time of review.

Based on review of recorded video footage, interviews, review of medical records of 1 of 3 patients who presented to the hospital's ED with law enforcement (Patient 1), review of central log documentation, and review of policies, procedures, and other documents, it was determined the hospital failed to enforce its EMTALA policies and procedures to ensure that Patient 1 was provided a MSE.

Findings included:

1. The hospital's policy and procedure titled "EMTALA (Emergency Medical Treatment and Active Labor Act)", dated as revised "12/15" was reviewed. It reflected the following: "It is the policy of the hospital to comply with the EMTALA obligations...The hospital will provide a [MSE] by a qualified medical provider to any individual who comes to the hospital seeking emergency medical treatment (or requested on their behalf); determine if the individual seeking care has an emergency medical condition (EMC); and, if an EMC exists, provide the individual with further medical examination and treatment as required to stabilize the [EMC] or arrange for transfer of the individual to another medical facility..."

The hospital's "Bylaws and Rules and Regulations of the Professional Staff", dated "September 2015" were reviewed. The section titled "Attendance of Patients in Emergency Situations" required that "An appropriate [MSE] within the capability of the hospital...shall be provided to all individuals who come to the [ED] and request (or on whose behalf a request is made) examination or treatment. Such medical screening shall be provided by qualified medical personnel."

The hospital's policy and procedure titled "Intake and Triage of the Emergency Patient at Westside Medical Center," dated as revised "07/15" was reviewed. It reflected the following: "...All patients presenting to the ED will be triaged by a [RN] and assigned an acuity number based upon their priority. The acuity is assigned using the Emergency Severity Index (ESI), and this acuity guides the prioritization of treatment. The results of the assessment must be documented and becomes a part of the patient's permanent medical record."

2. The ED central log was reviewed and reflected that Patient 1 arrived to the ED on 02/05/2016 at 1211. The "Reason for Visit" was recorded as "poh", the disposition was recorded as "[LWBS]", and the departure time was recorded as 02/05/2016 at 1225.

The ED medical record for Patient 1 reflected that the patient arrived by "Law Enforcement" in the ED on 02/05/2016 at 1211. The "Arrival Complaint" was recorded as "poh." The "Acuity" and "Escorted By" were blank.

At 1212, the CPCA recorded the patient's vital signs, height and weight; and that the patient was "roomed" in ED Triage Room B.

At 1212, the RN recorded "...DO assigned as Attending."

At 1220, the RN recorded "Went to lobby to speak with officer who brings POH. Advised officer that our hold room was RED, meaning occupied...Officer seemed comfortable with this and stated [he/she] would go to nearby [hospital]. As a newly trained ED CN I believed that this was an acceptable option. Pt and officer left the ED."

The record reflected the patient left the ED at 1225.

At 1235, the RN recorded "ED Registration does not accept the advice to remove the registration in error. Contacted the dept manager...to facilitate resolution. [Department Manager] advises to call [other hospital] and communicate the error. Information provided to me at this time to correct error. Even while in RED we still accept POH patients. This RN did not understand this and allowed [patient] to leave..."

The following sections of the record were documented as "No notes of this type exist for this encounter":
* H&P Notes
* Operative Report
* Discharge Summary

The "Pathology Results" section was documented as "No results found".

The "Diagnosis" section was documented as "None".

The "ED Disposition" was recorded "Patient left Kaiser Westside Emergency Department by Police Custody without Medical Screening Evaluation by an LIP".

There was no evidence in the medical record that the patient was triaged by an RN; and there was no evidence that the patient received a MSE in accordance with hospital policies and procedures. This was confirmed during an interview with the ED Nurse Manager on 02/17/2016 at 1030.

3. During interview with the Director of Accreditation, Regulation & Licensing on 02/16/2016 at 1440 he/she indicated that the hospital conducted an investigation of the case of Patient 1 after learning of a potential EMTALA violation involving the patient.

A document titled "Investigative Report" dated 02/12/2016 was provided by the Hospital Compliance Officer. The report reflected it was completed by the Hospital Compliance Officer. The report "Summary/Findings" reflected the following:

* "EMTALA Allegation: [Patient 1] arrived at Westside [ED] via police escort on 2/5/2016 at 12:11 pm and was registered by the [PAR]. The PAR notified...[CPCA] of the patient's arrival. [CPCA] attended to the patient and took [his/her] vitals."

* "This patient was [POH] which means the patient is in police custody and will need to be placed in a hold room...Westside ED was in 'red status' at the time of the patient's arrival - meaning that the hold room was occupied. The usual process is for the police to check this status prior to arriving. The police typically bring a POH patient through the ED back entrance, but in this case, the police arrived in the ED lobby."

* "After [CPCA] took the patient's vitals, [he/she] asked the patient to sit in the waiting area and said [he/she] would let the nurse know the patient had arrived. Knowing that [hold room] was occupied, [CPCA] said [he/she] needed to alert both the triage nurse and charge nurse."

* "[Triage Nurse] said [he/she] had a conversation with the police officer and informed [him/her] that the hold room was occupied. The police replied that if Westside ED was busy, [he/she] could go to [another hospital]."

* "[Triage Nurse] told the police that since the patient had already registered, it would be an issue if [he/she] left. [Triage Nurse] said [he/she] then notified [Charge Nurse] about the patient's arrival."

* "[Charge Nurse] said [he/she] went to talk with the police officer about 5 minutes after [Triage Nurse] notified [him/her] (about 12:30 pm). [Charge Nurse] was aware that [hold room] was occupied. [Charge Nurse] introduced [him/herself] and asked what [he/she] could do. The officer said [he/she] had a patient, but since Westside ED is on 'red status', [he/she] could take the patient to [another hospital]. [Charge Nurse] then replied, 'OK.'"

* "The officer and patient left the premises. [Charge Nurse] did not make any attempt to stop the officer and patient from leaving."

* "Other than the vitals, no other care was provided to the patient, including a medical screening exam, prior to [his/her] leaving the hospital."

* "Since the patient had been brought to the [ED] for medical treatment, the hospital had an obligation to perform a [MSE] to determine whether an [EMC] existed. This did not occur. Therefore, the allegation that EMTALA was violated is substantiated."

An interview was conducted with the Hospital Compliance Officer on 02/16/2016 at 1600. He/she confirmed the information in the investigative report involving Patient 1 above. The Compliance Officer stated that after completing the investigation, the hospital concluded that an EMTALA violation had occurred because the patient presented to the ED and no MSE was conducted.

4. Recorded video footage of Patient 1's 02/05/2016 ED visit was reviewed with the ED Nurse Manager on 02/17/2016 at 1010. The video footage was of the interior of the main ED registration and waiting area. The recording reflected the following:
* On 02/05/2016 at or around 1206 the patient and a police officer entered the ED waiting area from the direction of the ED entry.
* At or around 1215, the triage nurse approached the police officer and the patient. The patient was sitting in a chair with his/her back to the triage nurse. The triage nurse did not interact with the patient. Less than one minute later, the triage nurse left the waiting area.
* At or around 1216, the CN approached the police officer and the patient. The patient was sitting in a chair with his/her back to the CN. The CN did not interact with the patient.
* At or around 1217, the patient and the police officer walked out of the ED waiting area toward the ED entry.

There was no evidence in the video recording that reflected the patient was triaged by an RN, and there was no evidence that the patient received a MSE.

During an interview on 02/17/2016 at 1020, the ED Nurse Manager confirmed that the video recording reflected the patient was not triaged and no MSE was conducted. He/she stated "None of the nurses engaged with the patient" and "[The patient] wasn't here long enough for a medical screening exam."

Based on interview, documentation reviewed in 2 of 4 ED records of patients who presented to the hospital's ED with an EMC and who were transferred to other facilities (Patients 2 and 16), and review of hospital policies and procedures, it was determined that the hospital failed to effect all aspects of an appropriate transfers of those individuals as required by the hospital's policies and procedures. The hospital failed to ensure the required physician certification that the benefits of the transfer outweighed the increased risks of transfer. Patient specific risks of transfer were not identified for those patients.

Findings include:

1. Review of the hospital's policy titled "Transfer of Patient to Another Facility: EMTALA", dated as revised "07/15" was reviewed. It reflected the following: "...Transfers must be carried out according to the following guidelines...An individual who has a medical condition which is not stabilized may not be discharged or transferred for any reason unless one of the following conditions is met...The physician caring for the patient certifies the benefits for the transfer outweigh the risks of the transfer...Completion of the Transfer Form...When it is determined that an individual is to be transferred to another facility, the Transfer Form must be completed. All sections of the form must be completed prior to the individual being transferred...The "Physician Responsibility" section of the policy reflected "...Discuss the risk and benefit of the transfer with the individual or family member. Have the individual or family member denote if they agree or not with the transfer...Assure that all sections of the Transfer Form are completed. Certify the transfer by signing the form as the transferring physician, and date and time...Document on the transfer form the exact reason for transfer. Summarize the risks and benefits associated with transfer..."

2. The ED record for Patient 16 was reviewed. The record reflected the patient presented to the ED on 09/21/2015 at 1536. The RN notes recorded at 1609 reflected the patient's acuity was "3 [Urgent]."

The record reflected the patient received a MSE. Physician notes dated 09/21/2015 at 1617 reflected "...[Patient] presents to the [ED] complaining of [chest pain]...[chest pain] started yesterday, sharp. Pain is 8/10 at times. Comes and goes. Last pain episode w as (sic) 45min to an hr ago. Pain is mid chest, radiates to right arm. Has nausea and [shortness of breath] with it. The "Final Impression and Associated Conditions" section of the note reflected "...Acute MI" and the disposition reflected "...Transfer from WMC to [another hospital] for admission..."

The "ED Notes" documented by the RN at 1840 reflected "[Patient] transported via stretcher to [another hospital]..."

A form titled "Transfer Form" was reviewed. The top of the form reflected "All Sections Must Be Completed Prior To Transfer Of Patient." The "Physician" section of the form was signed and dated by a physician on 09/21/2015 at 1739. The "Risks of Transfer" section had a check box with an "X" in it followed by "Worsening of medical condition" and a line that was not completed and was blank. Below the blank line were the following instructions: "please specify patient specific."

There was no documentation to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks. This was confirmed during an interview with the ED Nurse Manager on 02/17/2016 at 1515.

3. Similar findings were identified during the review of the record for Patient 2.