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Based on review of facility documents, medical record (MR) and staff interviews (EMP) interviews, it was determined the facility failed to comply with 489.24 related to Medical Screening Examination and Appropriate Transfer.

Findings include:

The review of facility documentation revealed the facility failed to ensure an appropriate medical screening examination (MSE) was completed, to follow their approved policy and procedures for communication of information from physician to physician when patients were transferred to another facility, to follow their approved policy and procedures for communication of information from RN to RN when patients were transferred to another facility, and to ensure the Physicians Medical Necessity Certification for Transportation was maintained.

Cross reference with:
489.24(a) and 4892.24(c) - Medical Screening Exam
489.24(e)(1)-(2) - Appropriate Transfer

Based on review of facility policy and medical records (MR) and staff (EMP) interview, it was determined the facility failed to maintain a complete Emergency Department (ED) control log for April 1, 2021 through September 30, 2021.

Findings include:

Review on October 21, 2021, of the facility policy "Medical Screen Examinations, Stabilizing Treatment & Appropriate Transfers (EMTALA)," last approved August 25, 2021, revealed "Policy: Emergency medical treatment will be provided in compliance with the provisions of the Emergency Medical Treatment and Active Labor Act ("EMTALA") and other applicable laws and regulations. ... Central Log: A log that must be maintained on each individual who presents to the Emergency Department ("ED"), the Labor, Delivery and Recovery Department ("LDR"), or to any location on the hospital property, for emergency treatment. The Central Log must include: the patient's name and other identifying information; the presenting complaint; the disposition of each individual; whether he or she refused treatment; whether he or she was transferred, admitted and treated, stabilized and transferred or discharged. ..."

Review on October 21, 2021, of the facility's ED Central Log from April 1, 2021 through September 30, 2021, revealed the log did not document the disposition of 60 patients during that time frame. There were four patients without documentation of disposition in April 2021, six in May 2021, nine in June 2021, six in July 2021, 15 in August, and 20 in September 2021.

Continued review of the ED Central Log revealed during April 1, 2021 through September 30, 2021, there was no documentation of the patient condition at the time of transfer for 36 patients. There were four patients without documentation patient condition in April 2021, five in May 2021, eight in June 2021, two in July 2021, seven in August, and 10 in September 2021.

Interview with EMP1 on October 22, 2021, at approximately 1500, confirmed the Central Log entries during April 1, 2021 through September 30, 2021, contained no documentation of the disposition of 60 patients and no documentation of the condition of 36 patients at transfer.

Based on review of facility documents, medical record (MR), and staff (EMP) interviews, it was determined the facility failed to ensure an appropriate medical screening examination (MSE) was completed for one of one (MR1) applicable medical records.

Findings include:

Review on October 22, 2021, of facility policy ""Medical Screen Examinations, Stabilizing Treatment & Appropriate Transfers (EMTALA)." last approved August 25, 2021, revealed "Policy: Emergency medical treatment will be provided in compliance with the provisions of the Emergency Medical Treatment and Active Labor Act ("EMTALA") and other applicable laws and regulations. ... Emergency Services and Care: An appropriate medical screening examination and evaluation by a qualified medical professional and within the capability and capacity of Hospital, including ancillary services routinely available to the ED. This includes any care necessary to stabilize or eliminate the emergency medical condition. ... VI. Medical Screening Examination A. The MSE will be performed by a qualified medical professional B. The patient registration process will not delay the MSE or the stabilizing treatment of an EMC. C. The qualified medical professional who performs the MSE will document in the patient's medical record. ..."

Review on October 21, 2021, of MR1, revealed the patient resided in a Skilled Nursing Facility (SNF) attached to the hospital building. The SNF was within 300 feet of the hospital's Emergency Department (ED).

Interview with EMP4 on October 22, 2021, at 0745 revealed on October 4, 2021 at approximately 2000 they took a phone call from an RN at the SNF who asked to give report on MR1, as the facility was sending the patient to the ED for treatment. EMP4 handed the phone to EMP5.

Interview with EMP5 on October 22, 2021 at 0800 revealed they recalled taking a phone call from the unit clerk at approximately 2000 to speak with an RN at the SNF. The SNF RN reported MR1 was lethargic, did not know their name and had stable vital signs. EMP5 advised the SNF RN to keep MR1 at the SNF, as the ED was extremely busy. EMP5 stated ED staff were advised by the previous ED manager that since the SNF was on hospital property, it was acceptable to hold a patient in the SNF until a room in the ED became available.

EMP5 confirmed as the ED census and patient acuity dropped, the SNF was not contacted to have MR1 sent to the ED.

Interview with EMP1 on October 22, 2021, at approximately 1400, confirmed patients from other Skilled Nursing Facilities not physically attached to the hospital would not be advised to keep the patient until an ED bed became available.

On October 4, 2021, at 2226 a rapid response was called in the SNF, as MR1 was unresponsive, in asystole with no pulse or active respirations, and was unable to be aroused. ED staff responded to the rapid response in the SNF; cardiopulmonary resuscitation (CPR) was initiated; and the patient was taken to the ED for admission, as CPR continued.

CPR was ended at 2232, and the patient was pronounced deceased.

Based on review of facility policy and medical records (MR) and staff (EMP) interview, it was determined the facility failed to follow their approved policy and procedures for communication of information from physician to physician when patients were transferred to another facility in five of 17 applicable MRs reviewed (MR4, MR10, MR13, MR14 and MR21); failed to follow their approved policy and procedures for communication of information from RN to RN when patients were transferred to another facility in 12 of 17 applicable MRs reviewed (MR2, MR4, MR5, MR6, MR7, MR11, MR12, MR13, MR14, MR15, MR17 and MR21); and failed to ensure the Physicians Medical Necessity Certification for Transportation was maintained in 16 of 17 applicable MRs reviewed (MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR17, MR19 and MR21).

Findings include:

1) Review on October 21, 2021, of the facility policy "Medical Screen Examinations, Stabilizing Treatment & Appropriate Transfers (EMTALA)," last approved August 25, 2021, revealed "Policy: Emergency medical treatment will be provided in compliance with the provisions of the Emergency Medical Treatment and Active Labor Act ("EMTALA") and other applicable laws and regulations. ... IX. Transfers ... G. Before a patient is transferred, the physician who certifies the transfer must talk directly to a physician at the receiving facility in order to obtain the accepting representative's consent to the transfer and confirmation that the receiving facility is able to provide appropriate medical treatment to the individual. ..."

Review on October 22, 2021, of MR4, MR10, MR13, MR14 and MR21 revealed no documentation of physician-to-physician conversations.

Interview with EMP6 on October 22, 2021, at approximately 1330, confirmed there was no documentation of a physician-to-physician conversation regarding the transfers in MR4, MR10, MR13, MR14 and MR21.

2) Review on October 21, 2021, of facility policy "Transfer to Another Facility (Same or Higher Level of Care," last approved January 18, 2021, revealed "... Procedure: ... 7. A hand-off call will be made to the receiving facility and documented in the Medical Record, with RN to RN report prior to transfer."

Review on October 22, 2021, of facility policy "Transfer and Transport Arrangements," last approved January 14, 2021, revealed "... Procedure: ... 10. Prior to transport, the patient's clinical nurse calls clinical nurse at the receiving facility with a patient report of current clinical/medical status."

Review on October 22, 2021, revealed no documentation of RN-to-RN communication in MR4, MR7, and MR17 upon transfer to another facility.

Review of MR2, MR5, MR6, MR11, MR12, MR13, MR14, MR15, MR17 and MR21 revealed the named the individual at the receiving facility. The title of the individual at the receiving facility was not provided in the clinical nurse call documentation by the sending RN.

Interview with EMP6 on October 22, 2021, at approximately 13345, confirmed there was no documentation of RN-to-RN communication in MR4, MR7, and MR17 and no title of the individuals taking report in MR2, MR5, MR6, MR11, MR12, MR13, MR14, MR15, MR17 and MR21. EMP6 confirmed without a title documented it was not possible to determine if the individual taking report was an RN.

3) Review on October 21, 2021, of facility policy "Transfer to Another Facility (Same or Higher Level of Care," last approved January 18, 2021, revealed "... Procedure: ... 3. The physician determines what mode of transportation the patient requires and documents on PMNC. ... 5. The following forms must be completed with required signatures: Transfer EMTALA form Release of information form (optional) as necessary Physicians Medical Necessity Certification for Transportation (PMNC) form-as necessary ..."

Review on October 22, 2021, of facility policy "Medical Records Standards for Documentation and Chart Completion," last approved October 13, 2021, revealed "... Policy Statement The medical records of patients shall be maintained and completed in accordance with the rules and regulations detailed in the Medical Staff Bylaws and Rules and Regulations, Medical Record Standards and various accrediting and/or regulatory agencies. ... Interpretation ... 21. Pertinent transfer documents will be scanned into the EHR, along with the paper legal medical record documents per encounter, within 72 hours post discharge."

Review on October 22, 2021, of MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR17, MR19 and MR21 revealed each patient was transferred for a higher level of care via ambulance. The MRs did not contain the PMNC forms.

Interview with EMP6 on October 22, 2021, at approximately 1400, confirmed PMNC forms were not scanned into MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR17, MR19 and MR21. EMP6 further confirmed the original forms were given to the ambulance crew transporting patients to other facilities and not scanned into a patient's medical record.