HospitalInspections.org

Based on record review and interview this hospital failed to ensure they were in compliance with all Emergency Medical Labor and Treatment Act (EMTALA) requirements under 42 CFR 489.20 and 42 CFR 489.24. This facility failed to meet the 72 hour reporting requirements in 1 of 1 reportable EMTALA cases reviewed (Violation on 8/25/2017). Failure to maintain compliance with EMTALA requirements has the potential to affect all patients seeking care in this facilities Emergency Department.

Findings include:

Facility was made aware of a potential violation on 8/25/2017 and did not report to CMS or the State agency until 9/1/2017 (Reference 2401).

Based on record review and interview, this facility failed to meet the 72 hour reporting requirements for 1 of 1 reportable Emergency MedicalTreatment and Labor Act( EMTALA) violations reviewed (Violation on 8/25/2017). Failure to maintain compliance with EMTALA requirements has the potential to affect all patients seeking care in this facilities' Emergency Department.

Findings include:

The facility policy titled "EMTALA screening stabilization and transfer" dated 12/30/2015 was reviewed on 9/20/2017 at 2:20 PM. This document states "Each Medical Center physician or staff member who has reason to believe that a patient was inappropriately transferred to the Medical Center as a receiving hospital will immediately report the incident to Risk Management. Risk Management will report inappropriate transfers to CMS or the State survey agency within 72 hours as directed in Section 5.18."

An interview was conducted with Risk Manager A on 9/20/2017 at 11:30 AM. Risk Manager A stated A received a call from the Emergency Department (ED) on 8/25/2017 around noon reporting they received a patient from Wheaton St. Francis and had concerns about a potential EMTALA violation. Risk Manger A stated Bell ambulance reported to Aurora Sinai that a patient was refused at St. Francis. Risk Manger A attempted to contact Wheaton St. Francis on 8/25/2017 and again on 8/28/2017. Risk Manger A spoke with Bell Ambulance on 8/25/2017 at 3:00 PM. Bell Ambulance again reported St. Francis refused to take the patient. Leadership was updated on 8/31/2017. At that time hospital leadership at Aurora Sinai made the determination to report the potential EMTALA even though it was over the 72 hours. The potential EMTALA was then reported on 9/1/2017 at 8:35 AM to the state agency.