HospitalInspections.org

Based on a review of facility policy and staff interview (EMP), it was determined that the facility failed to ensure and maintain a medical record related to a patient transfer to another hospital.

Findings include:

Review of facility Policy and Procedure "Emergency Medical Treatment and Active Labor Act" reviewed March 2009, revealed, "C. Transfer of Individuals ... (ii) If an individual's emergency medical condition has not been resolved prior to transferring the individual to another hospital, the sending hospital has an EMTALA obligation and must meet these four requirements of an appropriate transfer: ... c. The transferring hospital sends to the receiving facility all medical records related to the emergency medical condition which is available at the time of transfer."

A request was made on September 17, 2015, at 9:35 AM to review the medical record of a patient who arrived by ambulance on July 9, 2015; however, no medical record was provided.

Interview with EMP1 on September 17, 2015, at 9:35 AM confirmed the above and revealed, "We got a phone call from [receiving hospital] that they were doing an audit and they did not have our record and requested it. When we looked into it, it was true. We didn't have any paper work. We didn't register the patient and we have no ER (emergency room) chart."

Based on a review of facility policy and documentation, and staff interview (EMP), it was determined that the facility failed to ensure and maintain a central log on each individual that presented to the emergency department.

Findings include:

Review of the facility's Policy and Procedure "Emergency Medical Treatment and Active Labor Act" reviewed March 2009, revealed "... A central log must be maintained for the hospital's dedicated emergency departments. The central log must include information on those individuals who come to the emergency department."

Review of the facility's Emergency Department Central Log for July 9, 2015, revealed no documented evidence of a patient who arrived by ambulance.

Interview with EMP5 on September 18, 2015 at approximately 11:00 AM confirmed the above findings and revealed "[The patient who arrived by ambulance] was never put on the log."

Based on a review of facility policy and documentation, and staff interview (EMP), it was determined the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's Emergency Department.

Findings include:

Review of the facility policy "Emergency medical Treatment And Active Labor Act" reviewed March 2009, revealed "... A Medical Screening Exam requires the facility to reach, with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. Depending on the patient's presenting symptoms, the medial screening examination represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing procedures and ancillary studies over a period of time such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans, and/or diagnostic tests and procedures."

A request was made on September 17, 2015, at 9:35 AM to review the medical record of the patient who arrived by ambulance on July 9, 2015; however, no medical record was provided.

A review of facility documents revealed no documentation of a patient who arrived by ambulance on July 9, 2015. Further review revealed no documentation that an MSE was completed.

Interview with Emergency Room Physician EMP4 on September 17, 2015, at 10:20 AM revealed "I seen him in the hall of the ambulance bay area. ... I didn't do the paper work. I wish I would have done the documentation."

Based on a review of facility policy and documentation, and staff interview (EMP), it was determined that the facility failed to ensure that the EMTALA requirements for an appropriate transfer were met, as the sending hospital.


Findings include:


Review of facility policy and procedure "Emergency Medical Treatment And Active Labor Act" reviewed 2009, revealed "....If individuals who come to the emergency department are transferred to another medical facility for care of an emergency medical condition the hospital must comply with EMTALA regulations for appropriate transfers ... (ii) If an individual's emergency medical condition has not been resolved prior to transferring the individual to another hospital the sending hospital has an EMTALA obligation and must meet these four requirements of an appropriate transfer: ... b. The receiving facility has agreed to accept the patient, has space and qualified personnel available for the treatment."

Review of the medical command audio recording revealed an ambulance staff giving report on the interventions and status of the patient. The recording also revealed that the ambulance staff stated, "ETA (estimated time of arrival) about 5 minutes." The audit recording ended with the facility's reply "message received."

An interview with EMP1 on September 17, 2015, at approximately 9:35 AM stated, "We got a phone call from [receiving hospital] that they were doing an audit and they did not have our record and requested it. When we looked into it, it was true. We didn't have any [documentation on the patient who arrived by ambulance on July 9, 2015]. We didn't register the patient and we have no ER (emergency room) chart."