HospitalInspections.org

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Based on observation, interview, record review, and review of hospital policies and procedures and medical staff bylaws, the hospital failed to develop and implement policies and procedures for evaluation and treatment of patients presenting for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to ensure patients who present for emergency medical treatment receive a comprehensive medical screening examination and stabilizing treatment prior to transfer or discharge risks poor patient care outcomes, injury, and death.

Findings included:

1. The hospital failed to investigate and analyze the circumstances surrounding a patient who may have been discharged in an unstable emergency medical condition from another hospital emergency department (ED).

2. The hospital failed to post signs specifying the rights of individuals under section 1867 of the Act and of its participation in the Medicaid program in all ED treatment areas.

3. The hospital failed to ensure that a patient who presented for emergency treatment received a medical screening examination prior to discharge and transportation to another hospital.

4. The hospital failed to provide evidence that a patient's medical records were sent to the receiving hospital when a patient was transferred to another hospital.

Cross Reference: Tags A-2401, A-2402, A-2406, A2409
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Based on interview, medical record review, and review of hospital policies and procedures, the hospital failed to investigate and analyze the circumstances surrounding Patient #1 who may have been discharged in an unstable emergency medical condition from another hospital emergency department (ED).

Failure to report hospitals who improperly transfer or discharge patients with unstable medical conditions risks poor health care outcomes, injury, and death.

Reference: 42 CFR 489.24(b) Definitions: Transfer means the movement (including the discharge) of an individual outside a hospital's facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the hospital...

Findings included:

1. Review of the medical records for Patient #1 showed the patient had been discharged from a local hospital ED on 04/06/19 following a drug overdose. After the patient was discharged, the patient's parents were concerned that the patient was not at his baseline behavior and brought him to the Kadlec ED. The patient presented with symptoms that included confusion, drowsiness, and shakiness. The patient was evaluated and treated in the ED for six hours. Treatment included intravenous fluids and medication.

2. On 05/30/19 at 1:10 PM, the investigator interviewed the hospital's Director of Risk Management (Staff #1) and asked if ED staff had reported Patient #1 as being a possible improper discharge under the EMTALA regulations. The director stated she had not received such notification.

3. Review of the hospital's policy titled "EMTALA - Emergency Medical Treatment and Active Labor Act Compliance (Anti-dumping), 1548.00," Policy #592903 approved 02/19, showed the policy directed staff to report patients who they believed had been transferred from another hospital without an appropriate medical screening examination to Quality Care Management, the Chief Operating Officer, or the Compliance Officer within 72 hours. The policy did not direct staff to report patients who had been discharged from another hospital ED in an unstable emergency medical condition.
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Based on observation, interview, and review of hospital policies and procedures, the hospital failed to post signs specifying the rights of individuals under section 1867 of the Act and of its participation in the Medicaid program in all ED treatment areas.

Failure to post such signage violates the patient's right to be informed of their rights under the Emergency Treatment and Active Labor Act (EMTALA).

Findings included:

1. Review of the hospital's policy titled "EMTALA - Obligations, 1548.01," Policy #5927921 approved 02/19, showed that the hospital would post EMTALA policy signs at all entrances, admitting areas, waiting areas, and treatment areas throughout the hospital.

2. On 05/29/19 at 12:30 PM, the investigator toured the main hospital's emergency department (ED). During the tour, the investigator inspected ED treatment areas for evidence of signage that informed patients of their rights under EMTALA. The investigator observed that there was no signage in examination rooms #9, #12, and #13 in the ED's "yellow zone".

3. During an interview with the investigator at the time of the observation, the ED assistant nurse manager (Staff #2) confirmed that there was no EMTALA signage in those ED examination rooms.
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Based on interview, medical record review, and review of hospital policies and procedures, the hospital failed to ensure that Patient #2 received a medical screening examination prior to discharge and transportation to another hospital.

Failure to ensure patients who present for emergency medical treatment receive a comprehensive medical screening examination and stabilizing treatment prior to transfer or discharge risks poor patient care outcomes, injury, and death.

Findings included:

Interviews and document review performed by the investigator during the complaint investigation showed the following:

1. Patient #2 was a 60 year-old patient who was transported on 05/12/19 by a Kennewick Police Department KPD) officer to the hospital's free-standing emergency department in Kennewick, Washington, for medical clearance prior to admission to a local crisis response facility. The patient's medical record showed the patient arrived at 12:34 AM and left at 12:53 AM. The records did not include evidence that the ED staff assessed the patient and performed a medical screening examination.

2. Review of a KPD police report dated 05/16/19 showed that when police first encountered the subject patient on 05/12/19 at 12:04 AM, the patient was suicidal and complained of difficulty breathing. The report stated when the officer took the patient to the free-standing ED he was informed that the patient was "trespassed" from that location and was asked to take the patient to a different hospital if possible. The officer contacted another local hospital and took the patient there for medical screening.

3. Document review and an interview with the hospital's Director of Risk Management (Staff #1) on 05/29/19 at 9:30 AM showed that the patient had a history of violent and disruptive behavior. The patient had been issued a "Trespass Admonition Form" on 03/22/19, which stated the patient was not allowed on hospital property unless he was seeking emergency medical treatment.

4. Review of the videotape of the event on 05/29/19 at 9:50 AM and an interview with the free-standing ED registration clerk (Staff #4) on 05/29/19 at 6:05 PM showed the patient was not violent or disruptive while in the ED lobby on 05/12/19.

5. During an interview on 5/29/19 at 5:55 PM, the charge nurse who was on duty 05/12/19 (Staff #6) stated there were two violent psychiatric patients being treated in the ED at the time of Patient #2's arrival. The nurse stated he called the nursing supervisor on duty (Staff #5) for advice. The supervisor told the nurse that if the free-standing ED was busy, the police officer could transport the patient to the main hospital ED for a medical screening examination.

6. During a telephone interview on 05/29/19 at 7:15 PM, the supervisor of the police officer who brought Patient #2 to the ED stated that the officer told him the ED charge nurse stated he would admit the patient for a medical screening examination but "preferred not to" due to the patient's history of violence and lack of resources related to two violent patients currently being treated in the ED.

7. An interview with the nursing supervisor (Staff #5) on 05/30/19 at 9:25 AM confirmed that the supervisor thought it was acceptable for the police officer to transport the patient from the free-standing ED to the main hospital ED without a medical screening examination.

8. Interviews with the hospital's Director of Risk Management (Staff #1) on 05/29/19 at 9:30 AM and with the hospital's free-standing ED manager (Staff #3) on 05/30/19 at 11:45 AM showed the hospital's investigation of the incident consisted of the ED manager interviewing and counseling the charge nurse that was on duty on 05/12/19 (Staff #6). The hospital's investigation did not include an in-depth analysis of the event to determine its root cause. The hospital did not develop a comprehensive action plan to reduce the chance of the event recurring.
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Based on interview, medical record review, and review of hospital policies and procedures, the hospital failed to provide evidence that a patient's medical records were sent to the receiving hospital when a patient was transferred to another hospital.

Failure to send medical records pertinent to the patient's care when transferred to another hospital risks poor patient care outcomes.

Findings included:

1. Review of the hospital's policy and procedure titled "Transfer to Other Health Care Facilities, 699.18.00," Policy #3878592 revised 09/17, showed that when a patient was transferred from the emergency department to another acute care facility, the hospital would provide the receiving hospital with copies of all appropriate medical records of the examination and the treatment performed. This would be documented on a Patient Transfer/Hospital Documentation form.

2. Review of the medical records of Patient #3, a patient diagnosed with active psychosis and methamphetamine use, showed the patient was evaluated in the hospital's emergency department on 01/12/19. Following the medical screening examination, the patient was medically cleared and transferred to a psychiatric hospital. The patient's ED record did not include evidence that the patient's medical records had been sent to the receiving hospital.

3. On 05/30/19 at 11:00 AM during an interview with the investigator, the nurse manager of free-standing ED (Staff #3) confirmed that there was no evidence in the patient's ED record that the medical records had been sent to the receiving hospital.
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