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Based on observations, 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 Labor Act (EMTALA) requirements.

Findings:

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

Tag A2402 - Posting of Signs - Based on observation and interviews, the facility failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) signage was posted at relevant locations in the facility.

Tag A2406 - Medical Screening Exam - Based on interviews and document reviews, the facility failed to ensure a medical screening examination was provided to a patient who presented to the emergency department for chest pain in one of three chest pain records reviewed (Patient #18).

Tag A2409 - Appropriate Transfer - Based on interviews and document review, the facility failed to provide completed Emergency Medical Treatment and Labor Act (EMTALA) forms for the transfer of a patient to an accepting facility in 1 of 1 obstetric transfer records reviewed (Patient #19).

Based on observation and interviews, the facility failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) signage was posted at relevant locations in the facility.

Findings include:

Facility policy:

The EMTALA (Emergency Medical and Labor Treatment Act) Policy read, the hospital will post conspicuously, in the dedicated emergency departments (ED) and labor and delivery and psychiatric units as well as all areas as defined above and all areas in which patients routinely present for treatment of emergency medical conditions and wait prior to examination and treatment (such as entrance, including ambulance bays, admitting areas, waiting room or treatment room), signs in the form of Attachments B and C that specify the rights of an individual under the law with respect to examination and treatment for emergency medical conditions and of women who are pregnant and are having contractions.

1. The facility failed to post signs specifying the rights of individuals seeking examination and treatment for emergency medical conditions and women in labor, at entrances and waiting areas used by patients seeking emergency services. Specifically, there was no EMTALA signage at the main entrance to the hospital.

a. On 11/11/19 at 9:40 a.m., upon entering the facility through the main entrance, observations revealed there was not an EMTALA sign posted at the main entrance to the facility.

b. On 11/13/19 at 12:15 p.m., an additional observation of the main entrance was conducted with Director of Quality Management (Director #2) who confirmed there was no evidence of a EMTALA sign posted at the main entrance. This was in contrast to policy which read, the hospital would post conspicuously, in the dedicated emergency departments (ED), labor and delivery, psychiatric units as well as the entrance to the hospital, signs which specify the rights of an individual under the law with respect to examination and treatment for emergency medical conditions and of women who are pregnant and are having contractions.

c. On 11/13/19 at 3:17 p.m., an interview with ED Assistant Nurse Manager (Manager #1) was conducted. Manager #1 confirmed patient seeking emergency services would present to the main entrance looking for the ED but was unsure why there was no EMTALA sign at the main entrance to the hospital. Manager #1 was unsure if there was no EMTALA sign how patients would be aware of their rights of as an individual under the law with respect to examination and treatment for emergency medical conditions and of women who are pregnant and are having contractions.

Based on interviews and document reviews, the facility failed to ensure a medical screening examination was provided to a patient who presented to the emergency department for chest pain in one of three chest pain records reviewed (Patient #18).

Facility findings:

Facility policies:

The EMTALA (Emergency Medical Treatment and Labor Act) policy read, it is the hospital policy that an individual comes to the Emergency Department (ED): The hospital will provide appropriate medical screening exam (MSE), within the capability of the hospital's dedicated emergency department, including ancillary services routinely available to the dedicated emergency department, to determine whether or not an emergency medical condition exists. The MSE is an ongoing process. The medical record must reflect ongoing assessment of the patient's condition. Monitoring must continue until the individual is stabilized, appropriately admitted or transferred. There should be evidence of this prior to discharge or transfer.

According to the policy's definitions:

Emergency medical condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in either (1) placing the health of the individual (Or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, or (2) serious impairment to bodily functions or (3) serious dysfunction of any bodily organ or part

The Medical Screening Exam (MSE): The screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist. Initial triage is not considered a MSE. The MSE represents a spectrum ranging from a brief history and physical examination to complex processes that also involve performing ancillary studies and procedures.

As defined per facility's AMA and Elopement policy:

Left without being seen (LWBS): A patient in the emergency Department, with or without decisional capacity, who has not been examined or treated by a Licensed Independent practitioner (LIP), and who leaves the patient care area without education on the risks, consequences, implications, and alternatives of this decision.

The Emergency Department Triage policy read, all patients will have an initial medical screening examination by a licensed independent practitioner (LIP).

Reference:

The Medical Staff and Allied Health Professionals Rules & Regulations, dated 2019, read Emergency Department personnel duties included performing a medical screening examination by a qualified medical person. A qualified medical person is an individual who has demonstrated current competence in performing the medical screening examination and includes emergency physicians, physician assistants, and nurse practitioners.

1. The facility failed to ensure patients presenting to the emergency department (ED) seeking emergency medical care received a medical screening examination (MSE) from a qualified medical person (QMP).

a. Review of Patient #18's medical record, dated on 3/11/19 at 1:50 p.m., revealed Patient #18 arrived at the ED with the chief complaint of chest pain. At 2:16 p.m., Registered Nurse (RN) #5 documented in a triage note Patient #18 had left anterior (towards the front) chest pain since midnight. RN #5 obtained the patient's vital signs and documented the patient rated her pain at a 6 on a scale from 0-10 with 10 being the worst pain.

At 2:19 p.m., RN #5 documented triage (the process of determining the priority of patients' treatments based on the severity of their condition) was complete. At 4:59 p.m., 2 hours and 40 minutes later, RN #5 obtained a second set of vital signs. Patient #18 still had not seen an ED physician, physician assistant, or a nurse practitioner to determine if a medical emergency condition existed.

At 6:08 p.m., over 4 hours later after arriving to the ED, Patient #18 was documented as LWBS (left without being seen).

On review of Patient #18's medical record there was no evidence the patient was seen and received a MSE by a qualified medical person (QMP), as defined by the Medical Staff and Allied Health Professionals Rules & Regulations, to determine if the patient had a medical emergency. This was in contrast to the EMTALA policy which read the hospital would provide an appropriate MSE, within the capability of the hospital's dedicated emergency department, including ancillary services routinely available to the dedicated emergency department.

b. On 11/13/19, ED Assistant Nurse Manager (Manager #1) provided the "ED Chest Pain" protocol which read a patient who presented to the ED with symptoms of atraumatic chest pain should have an electrocardiogram (a test which recorded the electrical signals in the heart) completed within 10 minutes. The electrocardiogram result was to be handed to a provider for interpretation.
There was no evidence in Patient #18's record which showed RN #5 followed the chest pain protocol. Additionally, RN #5 was not one of the ED personnel designated under the rules and regulations as a QMP who can perform a medical screening examination.

c. On 11/13/19 at 1:16 p.m., an interview was conducted with Emergency Medical Director (Physician #3). During the interview, Physician #3 stated a patient who presented to the ED with chest pain should receive an EKG (electrocardiogram) within 10 minutes. He said the EKG should immediately be taken to a physician to determine if a patient was experiencing a cardiac event. He said the purpose of the EKG was to rule out time sensitive information. Physician #3 stated treatment, including a cardiologist consultation and additional medical interventions, could be required based on the EKG results.

A review of Patient #18's emergency department visit was done with Physician #3. He stated the lack of an EKG was a deviation from the chest pain protocol. He said the patient waited a long time and did not receive an MSE by a provider. He stated an MSE was done to rule out any life threats which could cause deterioration of a patient.

d. During an interview with Manager #1 on 11/13/19 at 3:17 p.m., she stated the chest pain protocol was not followed in relation to Patient #18 and was unsure as to why. She reported there was a high volume of patients on 3/11/19, but the ED was adequately staffed and not on divert status (when incoming ambulances were directed to other facilities).

Manager #1 confirmed there was no EKG completed for Patient #18. She said the EKG should be done within 10 minutes for the provider to review and determine if the patient was having a STEMI (a very serious type of heart attack detected by ST-segment elevation, an abnormality on a 12-lead EKG).

Based on interviews and document review, the facility failed to provide completed Emergency Medical Treatment and Labor Act (EMTALA) forms for the transfer of a patient to an accepting facility in 1 of 1 obstetric transfer records reviewed (Patient #19).

Findings include:

Facility Policy:

The EMTALA policy read, the appropriate portions of the EMTALA Transfer From will be completed if the individual is transferred to another facility.

References:

The first page of the EMTALA transfer form obtained from the facility, particularly section titled Patient Consent to Transfer states that the patient has been informed of their rights regarding examination, treatment and transfer. The patient acknowledges that their medical condition has been evaluated and explained to the patient by the physician, who has recommended the patient be transferred to whichever doctor and facility. The potential benefits of such transfer, the potential risks associated with such transfer, and the probable risk of not being transferred has been explained to the patient and the patient fully understands them. With this knowledge and understanding, the patient agrees and consents to be transferred.

The second page of the EMTALA transfer form documents the patient's condition and transfer requirements including acceptance from another facility and physician, report between facility's registered nurse (RN) and accepting facilities RN, accompanying documentation, transportation and medical orders. The physician certification is also included on the form stating the reason for transfer.

1. The Facility failed to provide completed EMTALA forms for documentation of transfer. Specifically, there was not a signed patient consent to transfer explaining the risks and benefits of the transfer, documentation of accepting facility and physician, as well as the physician certification pertaining to the reason for transfer.

a. On 11/13/19, a medical record review was conducted for Patient #19. Review of the chart, revealed the patient first arrived in the ED on 9/13/19 at 5:01 a.m. Patient #19 complained of chest pain, elevated blood pressure, and a headache at 28 weeks gestation. Patient #19 was evaluated for possible pulmonary embolism (a blockage in one of the pulmonary arteries in the lungs). After labs and test were completed, the patient was then transported from the main ED to obstetrics (OB) triage at 9:31 a.m. for further emergency screening. It was determined the patient should be transferred to another facility for specialized care.

Review of the medical record for Patient #19 revealed no EMTALA transfer form to include, Patient #19 consented to the transfer, was notified by the physician the benefits of the transfer, the potential risks associated with the transfer, and the probable risk of not being transferred has been explained to the patient and the patient fully understood them.

b. The EMTALA forms for Patient #19 were requested from Director of Quality Management (Director #2). Director #2 was unable to provide the EMTALA forms for patient #19.

c. In an interview conducted on 11/13/19 at 12:48 p.m. with the Medical Director of Women's Services (Director #4). Director #4 stated the EMTALA form contains the physician certification and consent to transfer which demonstrated the patient has been examined, risks and benefits discussed and patient has consented to the transfer. Director #4 was unsure why this had not been done for Patient #19.

d. Registered Nurse (RN) #6 was interviewed on 11/13/19 at 3:07 p.m. on the transfer process and the completion of the EMTALA forms. RN #6 stated after the form was filled out, a copy is sent with the patient when they transfer and the other copy is then scanned into the chart. She further explained nurses fill out the nurse to nurse report section, and the physicians fill out the rest. The reason for the report section was to ensure the accepting nurse at the accepting facility has received report on the patient and has all the information needed to continue care of the patient. RN #6 stated she was unsure why this had not been done for Patient #19.