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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement, as defined in §489.24, related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

FINDINGS:

1. The facility failed to meet the following requirements under the EMTALA regulation:

Tag A2405 - Emergency Room Log

Based on interview and record review, the facility failed to maintain an Emergency Room Log that contained accurate information about disposition and transfer of patients that had received treatment in the Emergency Department (ED) for 4 of 40 records reviewed (Patients #13, #15, #18, and #19).

Tag A2406 - Medical Screening Exam

Based on interviews and document review, the facility failed to provide an appropriate Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Active Labor Act (EMTALA) regulation (Patient #3).

Tag A2409 - Appropriate Transfer

Based on record review, the facility failed to ensure patients transferred to a higher or specialized level of care were transferred with appropriate documentation of EMTALA specific requirements for 2 of 7 patients transferred (Patients #23 and #30).

Based on interview and record review, the facility failed to maintain an Emergency Room Log that contained accurate information about disposition and transfer of patients that had received treatment in the Emergency Department (ED) for 4 of 40 records reviewed (patients #13, #15, #18, and #19).

Findings:

POLICY

According to the policy titled Emergency Medical Treatment & Active Labor Act (EMTALA), the hospital will maintain a central log on each individual seeking or in need of emergency services. The log must include an indication whether the individual did not consent to treatment or transfer, or was transferred, admitted and treated, stabilized and transferred, or discharged.

1. The facility failed to maintain a complete and accurate central log of patients who presented to the Emergency Department (ED), including an accurate record of patients that were admitted, transferred or discharged.

a) Review of the Patient #13's medical record showed s/he presented to the ED on 05/31/16 at 2:11 p.m. for continued left-sided pain and was admitted for sepsis (a potentially life-threatening complication of an infection).

Review of the centralized log (EMTALA log) contained no documentation that Patient #13 presented to the ED on 05/31/16 at 2:11 p.m. and whether s/he refused treatment, was admitted and treated, stabilized and transferred or discharged.

b) Review of the EMTALA log, showed Patient #15 walked in to the ED on 05/31/16 at 5:06 p.m. with a rapid heart rate and was transferred to a short term acute hospital at 11:42 p.m.

However, review of an Emergency Physician Record, dated 05/31/16, revealed Patient #15 was seen in an off campus urgent care department of the hospital at 5:34 p.m.

Additional review showed Patient #15 was brought to the hospital's ED by ambulance on 05/31/16 at 6:54 p.m., approximately 2 hours later then what was documented on the central log. The central log also noted the patient walked into the ED while the medical record noted the patient arrived by ambulance.

c) Review of the central log revealed Patient #18 walked in to the ED on 06/03/16 at 9:40 a.m. with a rapid heart rate and palpitations. The log noted Patient #18 was transferred to a short term hospital on 06/03/16 at 1:18 p.m.

However, conflicting documentation in the ED record showed the patient was brought to the ED from an off campus department of the hospital by ambulance at 11:00 a.m. and was discharged home home at 1:24 p.m.

d) Patient #19 presented to the ED on 06/03/16 at 11:32 p.m. with a complaint of chest pain according to the central log. The log noted Patient #19 eloped on 06/04/16 at 1:41 a.m.

However, review of the ED Patient Discharge noted the patient was discharged home on 06/04/16 at 1:32 a.m.

Based on interviews and document review, the facility failed to provide an appropriate Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Active Labor Act (EMTALA) regulation (Patient #3).

This failure resulted in a delay in emergent care which created the potential for negative patient outcomes.

FINDINGS:

1. The facility failed to adequately treat and stabilize a patient who suffered a gunshot wound to the chest and presented to the facility for emergency services.

a) Medical record review revealed Patient # 3 sustained a gunshot wound on 11/27/15. The Pre-Hospital Care Report revealed that Emergency Medical Service (EMS) personnel transported the patient to the facility at 2:50 p.m. EMS records revealed no exit wound was located when the patient was examined by EMS personnel.

The Trauma Emergency Department Physician Record, completed by the Emergency Physician (Physician #6), dated 11/27/15 at 2:50 p.m., indicated the patient had sustained a gunshot wound to the left upper chest without an exit wound.

Review of the Trauma Record completed by the Registered Nurse (RN #5), dated 11/27/15 at 3:00 p.m., identified the chief complaint for Patient #3 was a left chest gunshot wound, with no exit wound.

The History and Physical Report, dictated at 3:17 p.m. on 11/27/15, contained a review of systems. The documentation revealed that on examination of the chest by a Physician Assistant (PA #7), there was an entrance and exit wound to the chest near the 7th rib. This was in contrast with the documentation from EMS personnel and the Emergency Department physician and nurse.

A chest x-ray was performed on 11/27/15 at 3:04 p.m. The chest x-ray report indicated no fracture or radiopaque (image) of a foreign body being present.

An x-ray of the kidneys, ureters, and bladder was performed on 11/27/15 at 3:02 p.m. The report indicated no bullet fragment was present.

The Physician Emergency Department Report dictated by the Physician #6, at 3:23 p.m. on 11/27/15, indicated Patient #3 had "an obvious gunshot wound with entry wound only to the left chest."

Review of documentation entered at 7:07 p.m. on 11/27/15 by RN #8, stated the Physician #6 was aware the patient reported increased pain, shortness of breath and difficulty lying down. Physician #6 documented "the patient was extremely anxious. [S/he] was convinced that [s/he] had a bullet in [his/her] chest or abdomen somewhere". Patient #3 was discharged from the facility at 7:41 p.m. on 11/27/15 with instructions to return if s/he experienced increased chest pain, difficulty breathing or problems.

b) The Emergency Department medical records for Patient #3 from two separate acute care hospitals were obtained. Patient #3 arrived at the second hospital on 11/27/15 at 11:42 p.m., just 4 hours after being discharged from the first hospital. Patient #3 complained of pain in the left upper abdomen that worsened with inspiration (breathing in). A computed tomography (x-rays taken from different angles) (CT) scan of the abdomen and pelvis was obtained on 11/28/15 at 1:51 a.m. The CT scan showed a left sixth fib fracture and a metallic object in the left lower quadrant mesentery (fold of tissue in the abdomen) presumably related to the gunshot wound. The hospital arranged a transfer for Patient #3 via ambulance to a third hospital in order for the patient to receive a higher level of trauma care.

c) Patient #3 arrived at the third hospital on 11/28/15 at 3:13 a.m. S/he was evaluated in the Emergency Department and taken to the operating room. A bullet fragment was removed from the mesentery and an injury to the diaphragm was repaired.

d) On 6/21/16 at 1:20 p.m. during an interview with the Trauma Program Manager, (Employee #3) s/he described the operations of the monthly multi-disciplinary Trauma Process Improvement and Patient Safety (PIPS) Committee. PIPS met monthly to review all operational aspects of the trauma program, identify problems in the system or processes and create an action plan to initiate changes if needed, monitor and evaluate results. The Chief Medical Officer, South State Operating Group (Physician #4) and the Chief Medical Officer (Physician #2) joined the interview to discuss further process improvement activities and peer review considerations. Physician #4 referred to Patient #3 and stated "we messed up on this case". The PIPS committee meeting minutes which documented the analysis of the assessment and treatment course for Patient #3 on 11/27/15 was reviewed. Physician #4 stated that on a date subsequent to 11/27/15, a nursing supervisor for the facility received an anonymous call which reported that Patient #3 had sought care at a different acute care hospital, where a bullet was identified in Patient #3's abdomen and was removed. The medical record from the other hospital for Patient #3 was attached to the PIPS committee meeting minutes. Physician #4 indicated that the occurrence had been sent to peer review for consideration.

Based on record review, the facility failed to ensure patients transferred to a higher or specialized level of care were transferred with appropriate documentation of EMTALA specific requirements for 2 of 7 patients transferred (Patients #23 and #30).

Findings

POLICY

According to the Physician Assessment and Certification For Transfer form the physician was to complete all shaded areas. Shaded areas included: Patient Condition, Transfer Requirements, Transportation (by qualified personnel) Medical Orders, and Physician Certification.

1. The facility utilized a two page EMTALA Transfer Form for patients transferred to a higher or specialized level of care. Medical record review revealed the transfer form was not completed in entirety and inclusive of critical information.

a) Review of the medical record for Patient #23 showed s/he presented to the emergency department (ED) on 06/15/16 at 3:51 p.m. with suicidal ideation. According to the Emergency Department Report, dictated on 06/15/16 at 3:55 p.m., the patient was to be evaluated by the psychiatric liaison and transferred to an intermediate care facility. The report noted the patient was cooperative and compliant.

Review of the Physician Assessment and Certification for Transfer form showed the Physician Certification section was not completed. There was no documentation as to why the patient was transferred.

Additionally, the mode of transportation section was not completed and there was no documentation the risks of being transferred had been discussed with the patient.

b) Review of the medical record for Patient #30 revealed s/he presented to the ED on 06/12/16 at 4:44 p.m. with a right hand laceration. According to the Emergency Department Report, dictated on 06/12/16 at 5:16 p.m., the patient was trying to remove a wire caught in a lawnmower without turning off the machine. The patient sustained significant lacerations to his/her right thumb, right index, right middle, right fourth finger and right small finger. The patient was to be flown to Denver for surgery.

Review of the EMTALA transfer form showed the mode of transportation, including the level of qualified personnel, the medical orders section and the physician certification, reason for transfer, sections were not completed.