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Based on 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 A2406 - Medical Screening Exam - Based on interviews and document review, the facility failed to ensure a Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation was provided by qualified medical personnel in 1 of 9 records reviewed for patients who presented to the emergency department and were transferred to another hospital (Patient #13).

Tag A2409 - Appropriate Transfer - Based on interviews and record review, the facility failed to ensure patients requiring a higher or specialized level of care were transferred appropriately pursuant to EMTALA (Emergency Medical Treatment and Labor Act) for 2 of 9 patients transferred to another hospital (Patients #15 and #19). This failure created the potential for patients to transfer without full disclosure of their rights and risks of transfer.

Based on interviews and document review, the facility failed to ensure a Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation was provided by qualified medical personnel in 1 of 9 records reviewed for patients who presented to the emergency department and were transferred to another hospital (Patient #13).

Findings include:

Facility policy:

According to the policy, EMTALA (Emergency Medical Treatment and Labor Act), when an individual comes to a Dedicated Emergency Department (DED) and a request is made by the individual or on the individual's behalf, for an examination or treatment of a medical condition, the DED must provide for an appropriate medical screening examination (MSE) within the capability of the facility. The purpose of the MSE is to determine whether the individual has an emergency medical condition (EMC).

Documentation - The following are required to be documented in the patient's medical record - the MSE, whether the patient has an EMC and necessary stabilizing care that was rendered, whether the patient was stable for transfer or discharge, the instructions given to the patient, parent or legally authorized representative and the completed Transfer Form.

1. The facility failed to ensure all patients who came to the emergency department seeking emergency medical treatment received an appropriate and complete MSE to determine if an emergency medical condition existed.

a) On 9/17/18 at 10:42 a.m., Patient #13 arrived at the emergency department (ED) with complaints of abdominal and rib pain and dry heaving. The ED Provider Notes for Patient #13 on 9/17/18 at 10:42 a.m. stated Medical Screening Evaluation - "I have provided a medical screening examination appropriate for [Patient #13's] chief complaint plus presenting signs and symptoms. Based on this screening examination, I have determined with reasonable clinical confidence that [Patient #13] does not have an emergency medical condition. [Patient #13] and caregiver(s) were provided options for obtaining further medical evaluation pertinent to their presenting concern. [Patient #13] is stable for discharge from this site to seek ongoing clinical care as discussed. Transferred to [another acute care hospital ED]."

There were no physical examination findings from the physician, diagnostic tests or procedure reports in the medical record to indicate how the physician made the determination that Patient #13 did not have an emergency medical condition. Nor were there physical examination findings from the physician, diagnostic tests or procedure reports in the medical record to indicate how the physician determined that Patient #13 did have an emergency medical condition requiring transfer to a different acute care hospital's emergency department.

According to the ED Decision to Transfer, dated 9/17/18 at 11:10 a.m., the patient was transferred to another acute care hospital for "Specialized treatment/service."

Review of the Pain Assessment, completed by Registered Nurse (RN) #3 on 9/17/18 at 10:48 a.m., showed Patient #13 complained of persistent stabbing abdominal pain rated at 6 (on a pain scale of 1 to 10).

b) An interview with the emergency department medical director (Director #1) was conducted on 12/27/18 at 4:01 p.m. Director #1 stated the facility was in the process of revising the policy addressing expectations for what should be documented when conducting an MSE. Director #1 indicated the current electronic documentation process allowed the practitioner to chose a pre-composed "smart phrase" for patients that presented, were screened and then went to a different hospital. Director #1 reviewed the physician documentation for Patient #13 and stated that this could be a situation where the wrong smart phrase was chosen.

Based on interviews and record review, the facility failed to ensure patients requiring a higher or specialized level of care were transferred appropriately pursuant to EMTALA (Emergency Medical Treatment and Labor Act) for 2 of 9 patients transferred (Patients #15 and #19) to another hospital. This failure created the potential for patients to transfer without full disclosure of their rights and risks of transfer.

Findings include:

Facility policy:

According to the policy, EMTALA (Emergency Medical Treatment and Labor Act), all dedicated emergency department patients that request a transfer or require a transfer for stabilizing care for an emergency medical condition will be transferred according to the requirements of EMTALA and the Transfer Form will be completed.

All EMTALA obligations are triggered, more specifically, the individual must receive a MSE (medical screening examination) and if an EMC (emergency medical condition) is determined to exist, stabilizing care for an EMC within the facility's capabilities and capacity must be rendered. If the facility lacks the capability and/or capacity to render the necessary stabilizing care for an EMC, an appropriate transfer will be affected.

Consent to transfer - The professional provider obtains signature from the patient/legally authorized represntative acting on behalf of the patient that an explanation of the evaluation of the patient's medical condition and potential risks associated with the transfer, and the potential risk of not being transferred was given to the patient/legally authorized representative acting on behalf of the patient.

The following are required to be documented in the patient's medical record: the MSE, whether the patient has an EMC and necessary stabilizing care that was rendered, whether the patient was stable for transfer or discharge, the instructions given to the patient, parent or legally authorized representative, completed Transfer Form.

1. The facility failed to ensure the EMTALA transfer consent form was completed. Additionally, the facility failed to ensure the transfer form was signed by the patient or legally authorized representative acting on behalf of the patient.

a) Review of Patient #15's medical record showed he was an 8 year old child brought to the Emergency Department (ED) by his mother on 1/9/18 at 2:47 p.m., with complaints of coughing, wheezing and trouble breathing. According to the ED provider's physical examination, dated 1/9/18 at 2:58 p.m., the patient was in respiratory distress, with decreased air movement and exhibited retraction (difficulty breathing).

Patient #15's condition did not improve during the course of treatment in the ED and the decision was made to transfer the patient to another hospital for further management. Patient #15 was transferred to another acute care hospital via ground ambulance at 8:19 p.m. on 1/9/18. No EMTALA Transport Form was present in the medical record indicating the parent's consent to transfer or the physician's certification that the medical benefits of transport outweighed the potential risks to the patient.

On 12/27/18 at 1:57 p.m., Accreditation Compliance Specialist (Specialist) #2 stated the facility was unable to locate the EMTALA Transport Form or consent for transfer for Patient #15.

b) Review of Patient #19's medical record showed the patient was an 18 year old who came to the ED on 12/14/18 at 5:16 p.m. with complaints of menstrual bleeding and abdominal pain. According to the ED provider's physical examination, dated 12/14/18 at 5:12 p.m., the patient was experiencing abdominal pain, nausea, vaginal bleeding and suicidal thoughts.

During the course of the ED treatment, the practitioner determined it was necessary to transfer Patient #19 to another hospital for evaluation of the patient's suicidal ideations. On 12/14/18 at 7:17 p.m., the physician completed and signed the physician certification statement on the EMTALA Transport Form, however the patient did not sign the EMTALA Transport Form indicating consent to the transfer.

c) On 12/27/18 at 1:57 p.m., Specialist #2 provided a copy of a presentation provided to frontline staff and practitioners, titled What you need to know about EMTALA. Instructions listed in the presentation for the EMTALA Transfer Form stated the form must be fully completed for all patients being transferred out, that the patient/authorized representative must be informed of the risks and benefits of the transfer and consent to the transfer and that the form needed to be signed by the ED physician.