HospitalInspections.org

.
Based on 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.
.
Based on documentation review and staff interviews, Facility A failed to:
.
A. Conduct a complete an appropriate Medical Screening Examination (MSE) for 1 of 20 patients (Patient #1) whose medical records were reviewed. Facility A failed to appropriately assess Patient #1's hypertension (184/124), resulting in Patient #1 driving herself to seek treatment at another facility while experiencing an emergency medical condition (EMC).
.
B. 1. Inform the individual of the risks and benefits to the individual of the transfer/discharge for 1 of 20 patients (Patient #1) whose records were reviewed.
2. Follow its policies regarding appropriate transfers/discharges as evidenced by:
a. No documented transfer attempts, such as contacting the receiving facility, documented efforts too to transfer Patient #1 to another medical facility, and no MOT was completed for Patient #1.
b. No documentation of staff informing Patient #1 of the risks and benefits of leaving Facility A with an elevated blood pressure of 188/124 and Patient #1 being allowed to drive herself to a receiving hospital.
c. Not obtaining a signed consent or refusal of a transfer by Patient #1.
.
Cross reference to Tag A2406 CFR §489.24(a) and §489.24(c).
Tag A2409 CFR §489.24(e)(1).
.

.
Based on record review and interview, Facility A failed to maintain written on-call policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions (EMC). The physician's duties as an on-call provider were not outlined within the policy, resulting in 1 of 20 patients whose records were reviewed not being seen for care upon presentation with an EMC.
.
Findings include:
Document Review:
The On-Call policy, last reviewed and effective as of 01/2023, outlined the on-call requirements for the "Administrator on Call". There were no provisions for the on-call hospitalist or behavioral health responsibilities if on-call. The policy did state on page 1 of 2:
" ...A. An On-call roster will be prepared and disseminated by the Chief Executive Officer on a
quarterly basis."
.
And on page 2 of 2:
" ...Physician On Call
Each Hospital will create a Physician On-Call Schedule. A physician will be available for consultation 24 hours per day ..."
.
Interviews
During interviews with Staff #4 (Director of Quality) and Staff #5 (Marketing Director of Intake and Admissions) on the afternoon of 08/13/2024, Staff #4 indicated that Facility A does not have a hospitalist or mid-level professional on duty 24/7 to complete examinations or provide stabilization and there is no current policy or bylaw in place defining the duties of an on-call provider and his/her duties.
.

.
Based on record review, and interview, Facility A failed to conduct a complete an appropriate Medical Screening Examination (MSE) for 1 of 20 patients (Patient #1) whose medical records were reviewed. Facility A failed to appropriately assess Patient #1's hypertension (184/124), resulting in Patient #1 driving herself to seek treatment at another facility while experiencing an emergency medical condition (EMC).
.
Findings include:
Policy Review
Facility A's Hospital Medical Staff Bylaws, last reviewed and effective as of 04/2024, was reviewed. The Hospital Medical Staff Bylaws was a 64-page document. The term "Qualified Medical Personnel (QMP)" was not found within the entirety of the document nor was the term "Medical Screening Examination (MSE)". There was no written policy stance outlining who could/should respond to an emergency medical condition (EMC) or meet the needs of patients presenting to Facility A's Emergency Department (ED) with an EMC.

A pending update to the Hospital Medical Staff Bylaws was provided and reviewed. The outline was under review at the time of this investigation. The review process was planned to be completed by Friday, 08/16/2024, and implemented immediately. The definition of a "Qualified Medical Personnel (QMP)" was defined as stated on page 4 of 10 of the pending documents:
" ....B. The Governing Board shall approve, in writing, the qualified medical personnel (QMP) who may perform the medical screening examinations (MSE) for EMTALA purposes.
1. Qualified Medical Person or Personnel (QMP) means an individual, in addition to a licensed physician, who is licensed or certified and who has demonstrated current competence in the performance of MSEs, for example:
i. Psychiatric Social Worker, depending on State law
ii. Registered Nurse in Psychiatric Services, depending on State law
iii. Psychologist
iv. Physician Assistant
v. Advanced Registered Nurse Practitioner ..."
.
Facility A's EMTALA Policy, last reviewed and effective as of 04/2024, was reviewed and stated on page 1 of 6:
" ...To ensure (Facility A) comply with the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) and associated regulations. All persons presenting to a (Facility A) will be provided a medical screening examination to determine if they have an emergency medical condition. This includes persons presenting for an examination or treatment at the request of the mental health authority, sheriff's office, or local police department ..."
.
And on page 3 of 6:
" ...Qualified Medical Personnel (QMP) means those individuals who are designated to perform the medical screening examination by the Hospital's Governing Board through the Medical Staff and/or Hospital Bylaws ..."
.
" ...Medical Screening Exam (MSE) includes both a general and focused assessment based on the patient's chief complaint with the intent to determine the presence or absence of an EMC. A psychiatric MSE should include a screening assessment by a QMP and then staffed with a medical provider to determine the presence of an EMC. Triage, or the completion of a medical/psychiatric triage form alone, does not satisfy the MSE requirement ..."
.
Facility A's Safety Assessment Policy, last reviewed and effective as of 01/2021, was reviewed. The Safety Assessment Policy stated on page 1 of 3:
" ...Purpose
To ensure a process for timely and effective screening of clients presenting for possible admission. To ensure patients are triaged and assessed in order of Mental Health and Medical needs ..."
.
And on page 2 of 3:
" ...Policy
To provide screening of all potential patients upon entering the facility for: reason for visit, recent thoughts of self-harm or harming others, safety, vital signs baseline, special equipment use, underlining medical conditions that may need acute medical attention, and blood sugar monitoring if insulin dependent ..."
.
Facility A's On-Call policy, last reviewed and effective as of 01/2023, was reviewed. The On-Call policy shared information on the on-call requirements for the "Administrator on Call". There were no provisions for the on-call hospitalist or behavioral health staff. The On-Call Policy stated on page 2 of 2:
" ...A physician will be available for consultation 24 hours per day ...".
Facility A's Transfer Policy, last reviewed and effective as of 12/2023, was reviewed and stated on page 3 of 10:
" ...Each patient who arrives at the Hospital shall be:
1. evaluated by a Physician who is present in the Hospital at the time the patient presents or is presented or
2. evaluated by a physician on-call who is (a) physically able to reach the patient within 30 minutes after being informed that a patient is present at the Hospital who requires immediate medical attention; or (b) accessible by direct, telephone, or radio communication within 30 minutes with a registered nurse, physician assistant or other qualified medical personnel as established by the governing body at the Hospital under orders to assess and report the patient's condition to the physician and
3. personally examined and evaluated by the physician before an attempt to transfer is made ..."
.
Medical Record from Facility A
The medical record for patient #1 was reviewed. The medical record revealed that Patient #1, a 47-year-old female, arrived by personal vehicle in Facility A's lobby on 06/10/2024, at 1:56 PM. Staff #8 (Receptionist) documented of every 15-minute observations beginning on 06/10/2024, at 1:56 PM. These observations ended at 2:45 PM. The medical record contained a "Safety Assessment Form" that was completed by Patient #1, which was not co-signed by any nursing or medical staff. The "Safety Assessment Form" contained a blood pressure that was documented at 2:02 PM by Staff #8 of 170/116. There was a second blood pressure documented by Staff #8 at 2:30PM of 188/124.
.
There was a note, written by Staff #7 (ED RN) on 06/10/2024, at 3:00 PM stating that Patient #1's initial blood pressure was 170/116 and her rechecked blood pressure was 188/124. The note further stated that Staff #8 referred Patient #1 to Facility B for medical clearance.
.
Patient #1 was documented as "referred out" and left the ED on 06/10/2024, at 2:53 PM in her private vehicle. The total time in the ED was 54 minutes. In that time a medical screening assessment (MSE) was not documented, a triage assessment was not documented, and there was no evidence contained within the record that a nurse or physician had assessed or seen Patient #1.
.
Emergency Department (ED) Central Log
Facility A's ED log shows that Patient #1 arrived at Facility A at 1:56 PM and was "referred out" at 2:53 PM.
.
Medical Record from Facility B
The medical record from the receiving facility, Facility B's, Emergency Department (ED) was reviewed. The medical record showed that Patient #1 arrived at Facility B at on 06/10/2024, at 3:08 PM with chief complaints of high blood pressure. Staff #10 (ED RN) noted "Patient states she went to go check into (Facility A) and was sent to the ED at (Facility B) for elevated BP (blood pressure)".
.
A triage assessment was initiated by Staff #10 on 06/10/2024, at 3:09 PM. All screening assessments and a review of Patient #1's past medical history and current medications were obtained. Patient #1's height, weight and vital signs were obtained at 3:13 PM. Patient #1 had an elevated blood pressure of 184/124 and an elevated pulse rate of 113 at that time. A Medical Screening Examination (MSE) was initiated by Staff #11 (ED Physician) on 06/10/2024, at 3:19 PM. Nine more sets of vital signs were obtained during Patient #1's time in Facility B's ED and her final blood pressure was normal at 115/69 on 06/11/2024, at 6:15 AM.
.
Patient #1 received three different blood pressure medications:
Clonidine 0.2mg was given orally on 06/11/2024, at 12:46 AM, 3:07 AM, and 3:25 AM.
Hydralazine 10 mg was given IV on 06/10/2024, at 5:32 PM and on 06/11/2024, at 5:18 AM.
Labetalol 10 mg was given IV on 06/10/2024, at 7:19 PM.
.
Patient #1 was discharged home on 06/11/2024, at 6:20 AM.
.
Interviews
On the morning of 08/13/2024, during an interview with Staff #5 (Marketing Director of Intake and Admissions), it was verified that Patient #1 did not receive an medical screening examination before leaving the facility. Staff #5 verified that Patient #1 drove herself to the receiving hospital after leaving Facility A. Staff #5 also verified that the document provided was the complete medical record for Patient #1 for the date of June 10, 2024.
.

.
Based on record review and interview, Facility A failed to inform the individual of the risks and benefits to the individual of the transfer/discharge for 1 of 20 patients (Patient #1) whose records were reviewed. Failed to follow its policies regarding appropriate transfers/discharges.
.
Findings included:
Facility A's EMTALA Policy, last reviewed and effective as of 04/2024, was reviewed and stated on page 4 of 6:
" ...Transfers
A. When a patient is being transferred from a (Facility A) to another medical facility because it does not have the capacity or capability to treat the patient's EMC, the following procedure will be followed:
1. Contact the on-call physician to initiate the Consent to Transfer EMTALA Form;
2. Call an Emergency Department able to provide appropriate care to the patient and obtain a verbal acceptance of transfer, including the name of an accepting physician;
3. Discuss transfer and risks with the patient;
4. lf the patient consents for transfer call EMS for transfer;
5. Complete and send a copy of the Consent to Transfer EMTALA Form and assessment to the receiving hospital; and
6. lf the patient refuses to be transferred and is not at imminent medical risK complete a copy of the Consent to Transfer EMTALA Form noting the patient's refusal, and complete assessment process ...

...C. The (Facility A) will call EMS or local sheriff's department for the patient's transfer to receiving hospital.
D. lf there is not a hospital able/willing to accept the patient for treatment and transfer, the (Facility A) must continue to provide stabilizing treatment within its capacity and capability ..."
.
Facility A's Transfer Policy, last reviewed and effective as of 12/2023, was reviewed and stated on page 3 - 4 of 10:
" ...Each patient who arrives at the Hospital shall be:
4. evaluated by a Physician who is present in the Hospital at the time the patient presents or is presented or
5. evaluated by a physician on-call who is (a) physically able to reach the patient within 30 minutes after being informed that a patient is present at the Hospital who requires immediate medical attention; or (b) accessible by direct, telephone, or radio communication within 30 minutes with a registered nurse, physician assistant or other qualified medical personnel as established by the governing body at the Hospital under orders to assess and report the patient's condition to the physician and
6. personally examined and evaluated by the physician before an attempt to transfer is made; however
a. after receiving a report on the patient's condition from the Hospital's registered nurse, Physician Assistant or other qualified medical personnel as established by the governing body by telephone, radio or audiovisual communication, if the Physician on call determines that an immediate transfer of the patient is medically appropriate and that the time required to conduct a personal examination and evaluation of the patient will unnecessarily delay the transfer to the detriment of the patient, the Physician on call may order the transfer by telephone, radio or audiovisual communication; and
b. if the on-call physician issues orders for the transfer of the patient by telephone, radio, or audiovisual communication, those orders shall be reduced to writing in the patient's medical record, signed by the registered nurse, Physician Assistant or other qualified medical personnel as established by the governing body receiving the order, and countersigned by the Physician authorizing the transfer as soon as possible."
.
Medical Record from Facility A
The medical record for patient #1 was reviewed. The medical record revealed that Patient #1, a 47-year-old female, arrived by personal vehicle in Facility A's lobby on 06/10/2024, at 1:56 PM. Staff #8 (Receptionist) documented of every 15-minute observations beginning on 06/10/2024, at 1:56 PM. These observations ended at 2:45 PM. The medical record contained a "Safety Assessment Form" that was completed by Patient #1, which was not co-signed by any nursing or medical staff. The "Safety Assessment Form" contained a blood pressure that was documented at 2:02 PM by Staff #8 of 170/116. There was a second blood pressure documented by Staff #8 at 2:30PM of 188/124.
.
There was a note, written by Staff #7 (ED RN) on 06/10/2024, at 3:00 PM stating that Patient #1's initial blood pressure was 170/116 and her rechecked blood pressure was 188/124. The note further stated that Staff #8 referred Patient #1 to Facility B for medical clearance.
.
Patient #1 was documented as "referred out" and left the ED on 06/10/2024, at 2:53 PM in her private vehicle. The total time in the ED was 54 minutes. In that time a medical screening assessment (MSE) was not documented, a triage assessment was not documented, and there was no evidence contained within the record that a nurse or physician had assessed or seen Patient #1.
.
There were no documented transfer attempts and not MOT was found for Patient #1, such as contacting the receiving facility, offering to transfer Patient #1 to another medical facility, informing Patient #1 of the risks and benefits to the individual of leaving Facility A with an elevated blood pressure of 188/124 and driving herself to a receiving hospital, or having Patient #1 sign a consent or refusal of a transfer.
.
Emergency Department (ED) Central Log
Facility A's ED log shows that Patient #1 arrived at Facility A at 1:56 PM and was "referred out" at 2:53 PM.
.
Medical Record from Facility B
The medical record from the receiving facility, Facility B's, Emergency Department (ED) was reviewed. The medical record showed that Patient #1 arrived by private vehicle at Facility B at on 06/10/2024, at 3:08 PM with chief complaints of high blood pressure. Staff #10 (ED RN) noted "Patient states she went to go check into (Facility A) and was sent to the ED at (Facility B) for elevated BP (blood pressure)".
.
A triage assessment was initiated by Staff #10 on 06/10/2024, at 3:09 PM. All screening assessments and a review of Patient #1's past medical history and current medications were obtained. Patient #1's height, weight and vital signs were obtained at 3:13 PM. Patient #1 had an elevated blood pressure of 184/124 and an elevated pulse rate of 113 at that time. A Medical Screening Examination (MSE) was initiated by Staff #11 (ED Physician) on 06/10/2024, at 3:19 PM. Nine more sets of vital signs were obtained during Patient #1's time in Facility B's ED and her final blood pressure was normal at 115/69 on 06/11/2024, at 6:15 AM.
.
Patient #1 received three different blood pressure medications:
Clonidine 0.2mg was given orally on 06/11/2024, at 12:46 AM, 3:07 AM, and 3:25 AM.
Hydralazine 10 mg was given IV on 06/10/2024, at 5:32 PM and on 06/11/2024, at 5:18 AM.
Labetalol 10 mg was given IV on 06/10/2024, at 7:19 PM.
.
Patient #1 was discharged home on 06/11/2024, at 6:20 AM. There was no documentation from Facility A found within this medical record that would indicate that any records were sent to Facility B.
.
Interviews
The above findings were verified during an interview on the morning of 08/13/2024 with Staff #5 (Marketing Director of Intake and Admissions). It was also verified that the document provided was the complete medical record for Patient #1 for the date of June 10, 2024.
.
In an interview on 08/13/2024 with Staff #5, the Marketing Director of Intake and Admissions, Staff #5 was asked if a transfer was offered or provided for Patient #1. Staff #5 stated that there was not, and that Patient #1 drove herself to the receiving facility (Facility B). Staff #5 further stated that anyone whose needs could not be met at Facility A and needed a higher level of care should have a transfer, but that some patients refused an EMS transfer. Staff #5 indicated that if an EMS transfer was refused, Facility A had a form for patients to fill out for refusing the EMS transfer. Staff #5 also indicated that Facility A failed to obtain a refusal of transfer for Patient #1.
.