HospitalInspections.org

Based on policy and procedure review, medical record review and interview, the hospital failed to adhere to the provider's agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements. See A2403 and 2409 for details

Based on clinical record review and interview, it was determined that the facility failed to maintain records for 19 (#6-#24) patients that presented to the facility for treatment. By not maintain these records the facility was not keeping an accurate record of the patient's course of treatment and care. The failed practice had the likelihood to affect all patients treated at the facility.
A. Review of facily's EMTALA (Emergency Medical Treatement and Labor Act) logs dated from 01/2024 to 07/01/2024 showed 24 patients were transferred out to other facilities prior to admission to the facility. All 24 clinical records were requested. There was no evidence of clinical records provided for Patients #6-#24.
B. The findings in A were confirmed in interview with the Interim Chief Executive Officer on 08/01/2024 at 9:15 AM.

Based on clinical record review and interview, it was determined that the facility failed to ensure that 2 (#1 and #4) of 24 (#1-#24) patients received an appropriate transfer in that the physician or mid-level practitioner did not sign the transfer form when transferring patients to outside facilities. Failure to ensure that the appropriate practitioners signed the transfer form did not ensure that the transfers were safe and appropriate. The failed practice had the likelihood to affect all patients needing a transfer out of the facility. Findings follow:

A. Review of Patient #1-#24's clinical record showed that Patients #1and #4 had been transferred to outside facilities and were marked as transfer out of the facility on the facilities EMTALA log.
B. Review of Patient #1, and #4 clinical records showed a Memorandum of Transfer (EMTALA) revised date of 12/2021. There was no evidence a physician or mid-level practitioner signed the Memorandum of Transfer. The signatures on the forms were of the facility's Registered Nurse Supervisor.
C. On 08/01/2024, a request was made to the Interim Chief Executive Officer (ICEO) for a policy regarding EMTALA transfers. There was no evidence of a policy on EMTALA transfers was provided.
D. The findings in A, B, and C were confirmed in interview with ICEO on 08/01/2024 at 9:45 AM.

Based on clinical record review and interview, it was determined that the facility failed to ensure that 3 (#2, #3 and #5) of 24 (#1-#24) patients had an appropriate transfer paperwork in the clinical record. Failure to ensure that the transfer form was a part of the clinical record did not ensure the transfer was appropriate, safe, or medically necessary. The failed practice had the likelihood to all patients transferred out of the facility. Findings follow:

A. Review of facility's EMTALA log showed that Patients #2, #3, and #5 were transferred out of the facility.
B. Review of clinical records for Patients #2, #3, and #5 showed there was no evidence of transfer documentation.
C. On 08/01/2024, a request was made to the Interim Chief Executive Officer (ICEO) for a policy regarding EMTALA transfers. There was no evidence of a policy on EMTALA transfers was provided.
D. The findings in A and B were confirmed in interview with ICEO on 08/01/2024 at 9:45 AM