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Based on record review and interview, the facility failed to maintain or have diagnostic radiologic services available under arrangement for 5 of 5 patient care units (Emergency Department/Intake Services, Adult Inpatient, Adult Outpatient, Adult Partial Hospital Program, and Adult Substance Abuse) in a total sample of 5 patient units.

Findings:

The facility failed to ensure that diagnostic radiological services are maintained or are available. See Tag A-0529

Based on record review and interview, the facility failed to maintain or have diagnostic radiologic services available under arrangement for 5 of 5 patient care units (Emergency Department/Intake Services, Adult Inpatient, Adult Outpatient, Adult Partial Hospital Program, and Adult Substance Abuse) in a total sample of 5 patient units.

Findings:

A review of the facility policy titled, "[Facility Name] Medical Conditions", effective date: 12/10/2022, revealed: "...IV. POLICY...C. Patients who require a level of medical treatment beyond the capabilities of staff, equipment, and the immediate services of [Facility Name] or the [Affiliated Facility Name] will be transferred, in accordance with EMTALA (Emergency Medical Treatment and Active Labor Act) guidelines, to another local hospital equipped and staffed to assess, diagnose, and treat the presenting medical problem..."

During an interview on 12/07/2022 at 10:56 AM with Director of Nursing (DON) B, when asked if there are radiologic Services offered onsite or if there are contracted services for any patient needing radiologic services, Director B stated "No, we send patients out to another [Facility Name] site if needed."

Based on record review and interview, the facility failed to ensure compliance with EMTALA (Emergency Medical Treatment and Active Labor Act) Regulations (Medical Screening Exam and Appropriate Transfer) for 1 of 11 patients (patient #1) in a total sample of 20 Emergency Department (ED) medical records reviewed.

Findings include:

The facility failed to ensure a medical screening exam was completed when a patient presents to the Emergency Department. See Tag A-2406

The facility failed to ensure appropriate documentation and communication was completed for patient transfers to another facility. See Tag A-2409

Based on record review and interview, the facility failed to ensure that a medical screening exam was completed per facility policy for 1 of 20 patients (patient #1) presenting to the Emergency Department (ED) in a total sample of 20 ED medical records reviewed.

Facility #1: receiving facility
Facility #2: transferring facility

Findings include:

An interview was conducted on 12/05/2022 at 10:20 AM with Complainant A for additional details not included in the original complaint submitted by Complainant A. Complainant A stated that upon arrival at facility #2, Pt. #1 was denied admission due to Pt. #1's involuntary status; facility #2 transferred Pt. #1 back to facility #1 via police without notifying facility #1 of the transfer.

A review of the facility policy titled, "[Facility Name] EMTALA (Emergency Medical Treatment and Labor Act)", last reviewed 09/15/2021, revealed: "...Dedicated Emergency Department ("DED"):...4. A location which has during the preceding calendar year, based on a representative sample, provided treatment of Emergency Medical Conditions on an urgent basis without an appointment for at least one-third (1/3) of all patients...IV. POLICY A. Hospital staff will provide an appropriate Medical Screening Examination (MSE) for all individuals that present to the DED with a medical condition or on the Hospital Campus with an Emergency Medical Condition..."

A review of Pt. #1's medical record revealed that there was no documentation of Pt. #1 being assessed (no MSE) in the Dedicated Emergency Department prior transfer from facility #2 to facility #1 on 10/26/2022.

During an interview with Executive Director of Access E on 12/07/2022 at 10:00 AM, Access E stated, "If a patient comes to the hospital requesting an assessment, the patient is directed to the Intake/Assessment room...Patient waits in waiting room area for RN (registered nurse) for MSE (medical screening exam), RN takes patient to 1 of 4 intake rooms and does an MSE..."

During an interview with Intake Patient Service Representative L on 12/07/2022 at 10:15 AM, when asked how he/she handles patients who come in for assessment, Representative L stated "I ask if they are here for an assessment, if they say 'yes' I explain the process....I inform nursing staff that patient is here for an assessment." When asked if he/she would ever turn away a patient, Representative L said "No."

During an interview with Intake Registered Nurse (RN) K on 12/07/2022 at 10:30 AM, when asked the process for patient assessment when they arrive, RN K stated "I bring the patient to an intake room and do an MSE."

During an interview with Director of Nursing (DON) B on 12/07/2022 at 10:35 AM, DON B confirmed that the facility has a Dedicated Emergency Department (DED), the facility provided treatment for patients presenting with an urgent medical need without an appointment to 1/3 of all patients during the preceding calendar year (2021).

During an interview with Director of Quality H on 12/13/2022 at 2:49 PM, Quality H confirmed that there was no documentation of Pt. #1 being seen at facility #2 upon arrival, "There was no documentation within the medical record. The patient was not seen. He/she came into the building but did not get registered, as they saw that the admission was canceled. An encounter was never created." When asked if Pt. #1 received a medical screening exam (MSE) upon arrival to [facility #2] on 10/26/2022, Quality H stated that Risk Manager S emailed Quality H on 12/13/22 at 12:43 PM that stated, "Patient (Pt. #1) did NOT receive an MSE (medical screening exam)."

Based on record review and interview, the facility failed to ensure that appropriate communication and documentation was completed per facility policy for 1 of 11 patients (patient #1) who were transferred to another facility in a total sample of 20 Emergency Department (ED) medical records reviewed.

Facility #1: receiving facility
Facility #2: transferring facility
Facility #3: facility where patient (Pt.) #1 first sought treatment

Findings Include:

A review of the facility policy titled, "[Facility Name] EMTALA (Emergency Medical Treatment and Labor Act)", last reviewed 09/15/2021, revealed: "...Transfer/Transferred: the relocation of a patient from one hospital to another hospital...D. Stabilization, Transfer, or Discharge...3. b) Recipient Hospital: A representative of the Recipient Hospital must confirm prior to transfer that: (1) The Recipient Hospital has available space and qualified personnel to treat the patient and agrees to accept the Transfer and to provide appropriate medical treatment; and (2) Hospital staff should document any communication with the Recipient Hospital, including the date and time of the Transfer request and the name of the person accepting the Transfer in the patient's medical record...c) Medical Record Transfer: The hospital staff shall send to the Recipient Hospital copies of all pertinent medical records available at the time of transfer, including: (1) Available history; (2) Records related to the patient's EMC (emergency medical condition) (3) Observations of signs or symptoms; (4) Preliminary diagnoses; (5) Results of any diagnostic studies or telephone reports of the studies; (6) Treatment provided; (7) Results of any tests; (8) A copy of the completed Patient Transfer Form..."

A review of Pt. #1's medical record revealed that there was no documentation of communication and transfer paperwork of Pt. #1's transfer from facility #2 to facility #1 on 10/26/2022.

A review of facility #2's "Safety Event" opened by facility #2's RN (name unknown) on 10/26/2022 and closed on 12/06/2022 by facility #2's Risk Manager S regarding Pt. #1's event on 10/26/2022 revealed, "(10/31/2022 at 7:52 AM) Patient arrived from [facility #1] by police and was sent back to [facility #1]. Patient was accepted for transfer to [facility #2] for inpatient treatment from another facility (facility #3). Prior to the transfer the patient became agitated and refused transfer to [facility #2]. Patient was taken to [facility #1] by police for possible Treatment Directors Supplement (TDS-a process in which two psychiatrists assess a patient for possible involuntary admission). At [facility #1] a Treatment Directors Supplement was initiated and the patient was transferred to [facility #2] without communication that the patient was coming or change in status (voluntary versus involuntary). [Facility #2] sent patient back to [facility #1], but was later admitted to [facility #2]. Investigation: See timeline of events attached in files."

A further review of the facility #2's safety event documentation indicates, "...0654 (6:54 AM) Patient leaves [facility #1] to [facility #2]...Patient left [facility #1] at 6:54 AM via MPD (city police department) car in a stable gait and with his/her belongings...0758 (7:58 AM) Patient arrives back to [facility #1], RN Note: The patient had been accepted at [facility #2], but was denied after he/she arrived there due to being on a TDS, he/she was then conveyed to [facility #1]..."

During an interview on 12/07/2022 at 10:37 AM with Director of Nursing (DON) B, when asked if facility #2 should have called facility #1 that Pt. #1 was being transferred to facility #1, DON B stated "Yes." When asked if there should have been transfer paperwork completed for Pt. #1's transfer, DON B stated, "Yes."

During an interview on 12/07/2022 at 11:15 AM with ED/Intake Manager C, when asked why Pt. #1 was transferred to facility #1 upon arrival to facility #2, Manager C stated "Because we did not have an acceptance and no bed assigned, the original acceptance was canceled." When asked if the facility was at full capacity, Manager C stated, "No, we were not at full capacity, just didn't have a bed assigned." Manager C confirmed that an admission order for Pt. #1 at facility #2 was entered on 10/25/2022 at 11:04 PM, and then admission orders for Pt. #1 were canceled on 10/26/2022 at 6:39 AM.