HospitalInspections.org

Based on interview and document review, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to obtain a consent from the [patient /guardian/responsible party] for an appropriate transfer to another facility for 4 of 4 patients (Patient's # 5, #,7, #8, and #19) resulting in the potential for less than optimal outcomes for all patients seeking emergent care. Findings include:

1. The failure to obtain a consent for transfer of a patient from one facility to another facility for care. (See tag 2409)

Based on document review, interview, and policy review the facility failed to log all individuals presenting to the Emergency Department seeking emergency services resulting in the failure to identify patients leaving the facility without being seen for emergency services and the potential for less than optimal outcomes for patients leaving the Emergency Department without being seen. Findings include:

On 8/17/2021 at 1030 a tour of the ED was conducted. The front lobby and waiting area had three patients waiting to be seen. Observation of the screener occurred as a patient was being served. On 8/17/2021 at 1035, an interview was conducted with Staff D, the ED screener / greeter. Staff D was queried what her role was with patients entering the ED. Staff D explained that she was responsible for screening patients for Covid-19 symptoms and to ask patients why the patient was coming to the ED. The screener explained that she wrote the patient's name, social security number , and reason for presentation to the ED. Staff D then explained that she would then take the piece of paper to the triage nurse. Staff D was then asked if the process would be any different for a patient presenting with depression or suicidal ideation. Staff D responded "yes ...I would take them directly over to the triage nurse." Staff D was asked if that would that be done with every individual presenting to the ED with depression and suicidal ideation. Staff D responded, "Yes." Staff D was queried if the registration clerk registers any patients prior to being triaged. Staff D stated, "No the triage nurse does a quick reg(istration) and the registration clerks see the patients off in the back (after patients have been triaged." Staff D was asked if there were any patients the hospital would not see. Staff D replied, "No." Staff D was asked if the hospital kept a list of frequent flyers or drug seeking patients. Staff D replied, "No." Staff D was then asked if she seeks any insurance information from the patients. Staff D stated, "No."

On 8/17/2021 at 1047, an interview with the Director of the ED, Staff C took place. Staff C was asked if nursing was responsible for registering the patient into the electronic system. Staff C stated the triage nurses performed a "quick reg" when the patient was being triaged. Staff C was then asked what registration's role was in the ED. Staff C stated the registration clerks obtained the insurance information once the patient was placed in the back of the ED after being triaged.

On 8/17/2021 at 1052, an interview was conducted with the ED triage nurse, Staff F. Staff F was queried about the process of triaging patients. Staff F stated that he was given a piece of paper from the screener and that he would call the patient from the piece of paper. Staff F was then asked would a patient with suicidal ideation or depression be handled the same as any other patient seeking ED care. Staff F stated, "anyone presenting to the ED with threats of suicide or complaints of severe depression, or any psychiatric complaint would be walked over by the screener. That patient would not be seated in the waiting area. We would get them immediately to the behavioral area that is located in the back." Staff F was then asked if there was not room in the back for a psychiatric patient what would happen with the patient. Staff F stated that the patient would be seated close to the nurse's station for safety. Staff F was asked if a sitter would be assigned to that patient. Staff F stated, "No. We would have to have a doctor's order to obtain a sitter." Staff F was then asked what his role was with registering patients seeking ED services. Staff F stated that he put in names, dates of birth, and the name of the patient's insurance. Staff F was queried if there were any insurances that the hospital did not accept for ED visits. Staff F stated, "No." Staff F was then asked if the ED had a list of any frequent flyer patients that were not to be seen. Staff F stated, "No." Staff F was then queried if he had training in EMTALA (Emergency Medical Treatment and Labor Act). Staff F stated, "Yes."


On 8/17/2021 at 1300 a document review of patient #1 medical record occurred. According to the Psychiatric (Telemedicine) Evaluation dated 6/24/2021 at 0917, the following was documented:
"43 y.o. (year-old) male with hx (history) of PTSD (post-traumatic stress disorder), MDD (major depressive disorder), GAD (generalized anxiety disorder), ADHD (attention deficit disorder) initially presenting to ED via EMS secondary to chief complaint of suicide attempt via intentional overdose on Ambien. Pt has been grossly non-compliant and aggressive/agitated with ED staff. SW documents that patient did acknowledge SI (suicidal ideation) but refused to discuss plan because it was "a secret." Known previous suicide attempts via hanging/overdose. Informed SW he has had very poor sleep, poor appetite, desire that someone would hurt him due to lack of will to live. Per documentation, Clinton Township PD (police department) received report from pt (patient) friend that the patient had consumed an excessive amount of alcohol plus 10 tablets of Ambien as a suicide attempt [however, later vacillates with another SW that he has not attempted suicide before; outpatient provider notes report he has not attempted suicide in the past.] Per chart review, PTSD related to significant amount of witness violence during incarceration from 2013 to 2019 [criminal sexual misconduct related to child pornography, on parole.] Informed SW also that he feels frustrated that he was turned away for bariatric surgery. Mychart (facility electronic chart) messaging notes he had messaged therapist on 6/21 acknowledging that his "depression is high" and "had dark thoughts all weekend." Pt was instructed to present to ED at which point he reported he did but left because his "blood" was "boiling."

On 8/17/2021 at 1325 during the document review of patient's #1 medical record, messages sent between the patient and the patient's primary care provider and the patient's therapist were reviewed. Documentation of the patient's messages on 6/21/2021 with Staff U, the nurse practitioner from the patient's family medicine group stated the following, "Might be time to increase meds.. depression is high.. had dark thoughts all weekend. At one point.. I was almost done done. My aggression is up..I actually feel worse the last few days than since my release. Only thing stopping me is that I've learned to drink.. a lot. Up for suggestions." On 6/22/2021 at 1725 a response was documented from Staff U. The response stated the following, "Hello, I've added your current appt to the waitlist for cancelations so we can get you in sooner to discuss options. I recommend avoiding alcohol with your medication. In the meantime, if you are unable to stay safe, please go immediately to the closest emergency department. Please review your safety plan and consider scheduling earlier or more frequent visits with (Staff V)." On 6/22/2021 at 1747 patient #1 responded, "Walking into an ER?
I've done that.. they put you in a room hoping you "calm down" or get bored to ask to go home and lie. I really wish people would stop suggesting ER or 911 in a mental crisis. Both.. I've proven useless." On 6/23/2021 at 1326 the patient also responded, "Went to ER..After waiting enough to make blood boil..I walked out."

On 8/17/2021 at 1330, Staff D was queried if any proof could be provided that the patient had sought emergent medical care in the ED. Staff D responded, "If the patient walked out without being triaged then there would be no record of him being at the facility." Staff D was then asked if all patients entering the ED were logged as presenting at the facility. Staff D responded if a patient leaves before being seen that the sheet of paper with the patient information is disposed of by the ED manager. The ED manager was unable to be reached at the time of survey. Staff D was asked how long the facility had the practice of not registering patients upon entry. Staff D responded, "Since the beginning of (electronic medical record) was implemented we (the facility) have not registered patients upon entry."

On 8/18/2021 at 1030 an interview was conducted with Staff N, the registration clerk. Staff N was queried about her role in the registration of patients. Staff N stated that she was responsible for gathering insurance information from patients once they were placed in an ED room. Staff N was then asked if she ever registered patients prior to the patient being triaged. Staff N stated, "We used to do that a long time ago but it's been years since we've done that ..." Staff N was then queried if she was aware of EMTALA requirements. Staff N stated, "yes."

On 8/18/2021 at 1400 a document review of the policy titled "Tier 1: Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance," dated 1/21/2021 was conducted. The policy failed to address keeping a log of patients entering the ED seeking treatment. No further policies could be provided for keeping a log of patients in the ED.

Based on interview and document review, the facility failed to get authorized permission (signature) from the patient/guardian/responsible party to authorize consent for the transfer of 4 of 20 patients (Patients #5, #7, #8, and # 19) to affirm acceptance/transfer of the patients at another facility for further treatment, resulting in an inappropriate EMTALA(Emergency Medical Treatment and Active Labor Act) transfer and the potential for unsatisfactory outcomes. Findings include:

On 08/18/21 at 1300 during review of medical records for patients #7 and #8, it was revealed that these two patients were both minors (under the age of 18). It was documented that each one of them had a parent who was "present at the bedside". The medical record did not contain the required signed documentation for a "consent to transfer" for further treatment at another facility.

On 08/18/21 at 1400 during review of medical records for patients # 5 and #19, it was revealed that the medical record for each of these two patients did not contain the required signed documentation for a "consent to transfer" for further treatment at another facility.

On 08/18/21 at 1545 during review of the document titled "Patient Transfer Form" (undated) under "Section 4: Consent to Transfer" the statement "I hereby consent to be transferred to Accepting Hospital: (Accepting hospitals name) risks associated with such transfer and the probably risks of not being transferred has been explained to me and I fully understand them." This statement required the signature of the physician and their title and the signature of the "Patient/Guardian/Responsible Party" and the "time/date".

On 08/18/21 at 1400, interview with Staff A, revealed that there was a "Patient Transfer Record" form that was "to be used for patient transfers to another facility according to our procedure" titled "Patient Transfer Form" that documented physician to physician communication, risks, benefits, and physician signature Staff A stated that they could not find any of the completed forms in the chart or down in the medicals records (Forms to be scanned into patient charts). A blank carbonless copy form was provided. A request for patient transfer policy and procedure was requested, and the "EMTALA Guidelines" was provided. Staff A stated, "We should have been using the form," on 08/18/21 at 1530.