HospitalInspections.org

Based on interview and record review, the hospital failed to meet the regulatory requirements under the Emergency Medical Treatment and Labor Act (EMTALA) as evidenced by:

1. The hospital failed to follow its policies and procedures in maintaining accurate and complete central logs of patients that presented to the emergency department and/or patients with transfer request that were refused by the emergency department. In addition, the hospital failed to revise its policy and procedure to reflect the use of the transfer center services in coordinating incoming and outgoing transfers. (A-2405)

2. The hospital failed to accept a transfer request for Patient 21 when the facility had the capacity and capability of treating the patient at the time the transfer request was made. (A-2411)

Failure to meet the EMTALA requirements could potentially compromise the health and safety of patients with an identified Emergency Medical Condition that require transfer for further care.

Based on interview and record review, the hospital failed to maintain accuracy and completeness of the Central Log (record reflecting the names and disposition of the individuals who comes to the Emergency Department [ED] seeking or in need of examination or treatment for an emergency medical condition. When the ED or transfer center staff register a patient in the computer, the patient is entered on the central log).

These failures had the potential of the hospital not being able to accurately track the care provided to the patients who comes to the hospital seeking care, and the appropriateness of any transfers that were refused by the ED.

Findings:

1. On 09/26/23 at 10:23 AM, an interview and concurrent review of the hospital's ED log from July to September 2023 was conducted with the Director of Quality.

Review of Patient 7's record revealed Patient 7 presented to the ED on 08/07/23, for a chief complaint of blood in urine. The record showed the physician conducted a medical screening exam (MSE) and Patient 7 was provided stabilizing treatment for his emergency medical condition (EMC). The disposition section of the ED log showed "not defined."

Review of Patient 8's record revealed Patient 8 presented to the ED on 08/10/23, for chief complaint of shortness of breath. The record showed the physician conducted an MSE and Patient 8 was provided stabilizing treatment for her EMC. The disposition section of the ED log showed "not defined."

When asked, the Director of Quality stated he did not know what "not defined" meant, and would refer the question to the Director of Emergency Services or the Medical Staff Coordinator.

Further review of the ED log revealed that out of 14,912 patients that presented to the ED from July to September 2023, 605 patients were entered a disposition of "not defined."

On 09/26/23 at 02:10 PM, an interview and concurrent chart review was conducted with the Director of Emergency Services, RN Leader, and the Director of Quality. The RN Leader stated the ED nurses were responsible in completing the ED log. The RN Leader stated the disposition section of the ED log was a mandatory field, "when they're discharging them [patients] in the system, that forces them to pick a disposition ...It's mandatory that you document in that field." Chart review showed Patient 7 was discharged and Patient 8 was admitted as inpatient. The Director of Emergency Services, RN Leader, and the Director of Quality verified the above findings.

On 9/27/23 at 10:15 AM, an interview was conducted with the Chief Executive Officer (CEO) and Chief Nursing Officer (CNO). Both CEO and CNO acknowledged the above findings and stated this was brought to their attention yesterday. The CNO stated "what that indicates to me is that 5% of the disposition were documented incorrectly ...When the ED Director presented this to me, we called informatics. When they looked at the chart, it was actually documented. It is an opportunity to improve."

2. On 09/27/23 at 08:12 AM, an interview and concurrent review of the Transfer Center Report for August and September 2023 was conducted with the Director of Quality. The Director of Emergency Services participated in the interview and record review at 08:28 AM.

The Director of Emergency Services stated when the Transfer Center took over in June 2023, " ...the Transfer Center were keeping the transfer log. Any incoming request goes to the Transfer Center, they keep the log of that, we don't keep the log anymore." The Director of Emergency Services was shown their current policy which was not consistent with their current practice of utilizing the Transfer Center. The Director of Emergency Services and Director of Quality confirmed that their policy needs to be updated.

Review of the Transfer Center Report for August and September 2023 revealed there were four ED transfer requests (Patients 21, 22, 23, 24, and 25) that were refused due to "MD decline." There were no notes or explanation documented for the physician's refusal to accept the transfer. The field for "Case Status Notes" were left blank. For example, on 08/08/23 at 04:52 AM, the Transfer Center received a request from Hospital B to transfer Patient 21. The log showed the following entries:
- initial request: ER Transfer
- complaint: Fracture - Hand
- Service Line Requested - HAND [ortho]
- Case Status: Declined
- Case Status Explanation: MD Decline
- Case Status Notes: [blank]

The Director of Quality and the Director of Emergency Services verified the above findings and stated by reviewing the entries in the Transfer Center Report, they would not be able to tell the reason for the refusal nor verify the appropriateness of the transfer requests that were refused by the physician.

On 9/27/23 at 10:15 AM, an interview was conducted with the hospital's CEO and CNO. Both CEO and CNO acknowledged the above findings. The CEO stated "what happens is, we get these reports, we are looking for three things...if it's an MD decline and it is not documented, it is our understanding that it is within their protocol, a service that we do not offer...illegitimate reason is addressed to the physician right away ...if it is not to our hospital, sometimes it is documented as [name of hospital], that we give the feedback to our sister hospital." The CEO continued "if there's no notes what we found sometimes is the transfer center service thinks we have the service. We need to be tighter in documenting ...that is an opportunity for improvement."

Review of the hospital's policy and procedure titled EMTALA with effective date of 02/14/23, revealed "If an individual comes to the department ...C. Central Log 1. The Hospital must maintain a central log of individuals who come to the emergency department and include in such log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged. The log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE [Medical Screening Examination]."

"I. Obligation to Accept Transfers ...2. Personnel who accept or reject another facility's request for transfer must record the request , the response to the request, and the basis for any denial of such a request, in a patient request log which should be maintained in the Emergency Department in order to document the appropriateness of any transfers that were refused by the Emergency Department."

Based on interview and record review, Hospital A failed to meet its Recipient Hospital Responsibilities for one of 25 patients (Patient 21). Hospital B contacted Hospital A on 08/08/23 to transfer Patient 21 who required hand surgery , a service which Hospital B did not have the capability to provide. Hospital A refused to accept Patient 21 even though Hospital A had the capacity and capability to accept and provide the surgical services to Patient 21.

The deficient practice had the potential to delay treatment of patients with emergency medical conditions requiring hospital transfers.

Findings:

On 09/26/23 at 08:00 AM, an investigation was initiated at Hospital A after a complaint was received regarding a possible Emergency Medical Treatment and Labor Act (EMTALA) violation related to Recipient Hospital Responsibilities.

Review of Hospital B's Emergency Documentation for Patient 1 revealed that Patient 21 was registered as a patient in Hospital B's Emergency Department (ED) on 08/07/23 at 09:04 PM. Patient 21 presented to the ED complaining of crush injury to the right fourth digit sustaining a laceration from work. X-ray showed fracture of the distal aspect of the right fourth digit, requiring hand surgery. Hospital B did not have the capability to provide the specialty service to Patient 21.

Review of Hospital B's audio recording of the telephone calls coordinated by the transfer center revealed a request was placed for a higher level of care due to Hospital B not having the specialized services that Patient 21 needed. The transfer center staff representing Hospital A's healthcare system checked several facilities that could accommodate Patient 21's required services and found that Hospital A had the capacity and capability to provide the surgical services that Patient 21 needed. The audio recording further revealed Hospital B's Physician Assistant (PA) spoke and discuss Patient 21's case with Hospital A's ED physician. Hospital A's ED Physician informed Hospital B's PA that she needed to run this by their hand surgeon. Hospital A's ED Physician asked the transfer center staff how far the referring facility was from Hospital A, to which she was told approximately two hours away.

Review of a follow-up audio recording from Hospital B's transfer center, revealed Hospital A's transfer center staff informed Hospital B's staff that Hospital A's hand surgeon declined to accept Patient 21 " ...due to the fact that they were two hours away and the patient would need to follow-up and the surgeon did not think that the patient would want to follow-up that far away."

Review of Hospital A's Transfer Center Report for the month of August 2023, revealed Hospital A's transfer center received a call from Hospital B on 08/08/23 at 04:52 AM. The Transfer Center received a request from Hospital B to transfer Patient 21. The log showed the following entries:
- Initial Request: ER Transfer
- Complaint: Fracture - Hand
- Service Line Requested - HAND [ortho]
- Case Status: Declined
- Case Status Explanation: MD Decline
- Case Status Notes: [blank]
- Referring Location Source: Hospital ED
- Referring Location Reason for Transfer: HLOC (higher level of care)
- Request Priority: Emergent

Review of Hospital A's call schedule for August 2023, revealed Physician (MD) 1 was scheduled on-call for Ortho-Hand (doctors who specialize in surgery of the hand) from 08/07/23 to 08/14/23.

On 09/26/23 at 04:20 PM, a telephone interview was conducted with MD 1. MD 1 stated she was the on-call physician for hand surgery at Hospital A on 08/08/23. MD 1 stated she received a phone call from the ED Physician in the early morning of 08/08/23, regarding a "transfer inquiry." MD 1 stated "...I think what I said was if it could be managed locally, if there's any issues call me back ...I didn't decline." When asked what she meant by "transfer inquiry," MD 1 stated "I think when people call you to ask if something is appropriate for transfer." MD 1 stated at the time the call was made, they [Hospital A] have the capacity and a capability to provide the surgical services that Patient 1 needed. MD 1 stated "...what I said [to the ED Physician] that in my opinion what happens with patients who are managed far from where they live, potentially what is happening was they lost follow-up...But that is not the reason that I decline."

On 09/26/23 at 04:40 PM, a telephone interview was conducted with Hospital A's ED Physician. The ED Physician confirmed that Hospital B "...did call through the transfer center for the ortho hand specialty care, so then I spoke with our hand surgeon [MD1]. The ED Physician stated she felt it was an appropriate transfer "...so from what I can recall...I communicated to her [MD1] that there was a tendon injury of the digit and they [Hospital B] did not have hand specialty ...she [MD1] felt that the follow-up care would not be on the best interest of the patient ...she felt that the patient would need to have a lot of follow-up care and because of the distance, the patient would not get appropriate care." The ED Physician stated she communicated "...to the secretary that our hand specialist felt it was inappropriate transfer and that that we are declining the transfer."

On 9/27/23 at 10:15 AM, an interview was conducted with Hospital A's Chief Executive Office (CEO) and Chief Nursing Officer (CNO). Both CEO and CNO acknowledged the above findings. The CEO stated " ...from my standpoint, if we have the service, what I have been educating people is, if somebody says they need help, let's get the patient here." The CEO stated if the hospital had the capability and capacity to provide the service, " ...geography is not the point. Yes, it would be better for the patient, but it's not our decision and that has been clarified with the ER and the hand surgeon team."

According to Hospital A's policy and procedure titled EMTALA with effective date of 02/14/23,

"I. Obligation to Accept Transfers

1. To the extent that the Hospital has specialized capabilities (including capabilities available through the Hospital's on-call roster) or facilities, such as burn unit, a shock-trauma unit or neonatal intensive care unit, that are not available at the transferring facility, the Hospital must accept appropriate transfers of an individual needing such specialized capabilities or facilities if the Hospital has the capacity to treat the individual.

2. The following personnel or categories of personnel are authorized to accept or reject transfers from another hospital on behalf of the Hospital: House nursing supervisors, and Emergency Department physicians."