HospitalInspections.org

Based on interview and document review the facility failed to report within 72 hours the inappropriate transfer of a patient failed to have communication from hospital A to hospital B for the acceptance of the patient in 1 (#1) of 22 patients resulting in failure to report the inappropriate transfer of an emergent patient. Findings include:

On 3/14/18 at 1000 an interview with confidential informant A revealed patient #1 had been picked up from her home via ambulance owned by Hospital A and transported to Hospital B. The informant stated that patient #1 did not receive a medical screening exam prior to transport to Hospital B . The informant stated this information was reported to Hospital B, specifically that the Hospital A had violated the Emergency Medical Treatment and Labor Act (EMTALA) by "dumping the patient" at Hospital B.

On 3/20/2018 at 1540 a document review of patient #1's medical record at Hospital B occurred. Patient #1 was a 79-year-old female who presented to the emergency department (ED) via ambulance on 2/8/2018 at 1758. Review of the ambulance run sheet revealed the patient was picked up from her home in a town approximately 41 miles away from the facility (per an online global positioning service (GPS) map). The patient stated a chief complaint of abdominal pain and nausea/vomiting. Further review revealed the patient was diagnosed with pneumonia and hospitalized at the facility from 2/8/2018 to 2/10/2018.

On 3/21/2018 at 0900 a review of the facility's complaint and grievance log was conducted. The log was void of any complaints related to EMTALA.

On 3/21/2018 at 1130 an interview was conducted with staff E, patient liaison. Staff E was queried if he had received a complaint regarding patient #1. Staff E stated "yes...I received a phone call from (a complainant) who stated she felt as though the patient had been diverted from (hospital A)... she also stated that she felt it was an EMTALA violation." Staff E was queried why the complaint was not on the facility's complaint and grievance log. Staff E stated "because the patient and family member had agreed to come to (the facility), I was under the assumption that the choice was theirs." Staff E was then asked if he had alerted hospital A of the complaint. Staff E stated "yes...I forwarded the complaint to hospital A and I also sent information to the complainant on how to file a complaint with the state." Staff E was queried if he understood it was an EMTALA regulation to report any incident of improper transfer or receipt of a patient. Staff E stated "It wasn't until the complainant contacted me that I was even aware of incident and with the documentation presented by the EMS (emergency medical services) team it was not clear to us that this was an EMTALA violation that needed to be reported." Staff E was then asked if the complainant had stated it was an EMTALA violation. Staff E stated "yes, she did mention she felt it was an EMTALA violation." Staff E was queried if EMTALA was mentioned when he informed hospital A of the complaint. Staff E responded "yes." Staff E went on to explain "I would inform any facility of a complaint received here when another facility is involved...it has nothing to do with the hospital (A) being a facility also under our healthcare corporation."