HospitalInspections.org

Based on interview, and record review, the hospital failed to ensure that it was in compliance with the Emergency Medical Treatment and Labor Act (EMTALA) as evidenced by the following:

1. Appropriate medical screening examinations were not performed for three of 30 sampled emergency department patients. (Patients 13, 14, and 30) (Refer to A 2406, findings 1-3).

2. Physician transfer certifications (documentation) for seven of 10 sampled transferred patients did not meet the requirements for an appropriate transfer for as follows:
a. Patients 7, 8, 9 and 10's "Physician Certification" did not contain proper authentication by the physician with a signature, date and time. (Refer to A 2409, findings 1-4)

b. Patients 7, 8, 9, 10, 11, 15, and 16's, "Physician Certification" did not contain:
* A description of the higher level of medical services that would cause the transfer to benefit the patient,
* The medical benefits reasonably expected from the provision of the medical services available at the receiving facility, and that those benefits outweigh the increased risks to the individual from being transferred, and
* A summary of the risks and benefits upon which the certification was based. (Refer to A 2409, findings 1-7)

c. Patients 7, 8, and 10's, "Physician Certification" contained information that indicated the patients had been transferred using other than qualified personnel and transfer equipment. (Refer to A 2409, findings 1, 2, and 4)

These failures have the potential for patients to have delays in receiving needed care and inappropriate transfers to another facility which could result in adverse outcomes including death.

Based on interview and record review, the hospital failed to ensure that that the central logs used in the Emergency Department (ED) and the Obstetrical (OB - for birthing) Departments were complete for 127 patients with the required information as follows:

1. The ED logs contained blanks for 26 of 4567 patient entries for the chief complaint, the arrival time, discharge time, and/or disposition (where the patient went following discharge).

2. The OB log contained blanks for 37 of 332 patient entries for chief complaint, discharge time, and disposition.

These failures had the potential for miscommunication and the inability to assess the compliance with CFR 489.20- 489.24 requirements.

Findings:

1. On 6/2/14, the ED logs from 5/1 to 5/31/14 were reviewed. The ED log contained 17 patient entries that were blank for chief complaint and arrival time of the 4567 patients who presented to the ED. The ED log contained nine patient entries that were blank for discharge time and disposition.

On 6/4/14, the hospital policy, titled, "EMTALA - Emergency Medical Treatment and Labor Act," dated 7/7/11, read, "Central Log: Each department that provides medical screening examinations shall maintain a central log including at least the following information: 1) names of patients who present for emergency services, 2) whether the patient refused services, 3) whether the patient was refused treatment or whether the patient was transferred, 4) if the patient was admitted and treated, 5) if the patient was stabilized and transferred or discharged.

On 6/3/14 at 11:45 am, the Director of Emergency Department reviewed the above logs and acknowledged that the logs contained blanks and should be completed in full.

2. On 6/3/14, the OB logs from 5/1 to 5/31/14 were reviewed. The OB log contained 37 patient entries that were blank for chief complaint; five patient entries that were blank for disposition; four patient entries were blank for estimated date of confinement (EDC - due date) and 59 patient entries that were blank for discharge time of the 332 patients who presented at the OB department.

On 6/4/14, the hospital policy, titled, "EMTALA - Emergency Medical Treatment and Labor Act," dated 7/7/11, read, "Labor and Delivery Log: A log entry shall be made for any individual who presents to labor and delivery for care. The entry shall include individual's name chief complaint, estimated date of confinement (EDC), and disposition."

On 6/4/14 at 10 am, the Director of Perinatal Services reviewed the OB logs and acknowledged that there were numerous blanks and that each patient entry should be complete.

Based on interview and record review, the hospital failed to ensure that three of 30 sampled patients (Patients 13, 16, and 30) who presented to the hospital emergency department (ED) had an appropriate medical screening exam (MSE) to determine whether an emergency medical condition (EMC) existed.

1. Patient 30 presented to the ED on 5/16/14 and did have evidence of a MSE in the record.

2. Patient 13 presented to the ED pregnant with chronic chest pain. Patient 13's MSE did not include physical exam findings, or information pertinent to her pregnancy.

3. Patient 14 presented to the OB (Obstetrical - birthing) Department with concerns that her baby was not moving. Patient 16's MSE did not contain all of the elements of a full assessment as outlined in the hospital policy.

These failures had the potential for emergency medical conditions to go undetected and result in a decline in the patients' health status including death and/or fetal demise (death of the unborn child - fetus).

Findings:

1. A review of Patient 30's record indicated she presented to the emergency room with severe abdominal cramping and had a history of a gastric bypass surgery (a weight loss surgery that makes the stomach smaller) within the last year. Approximately nine hours later, Patient 30 was transferred to the hospital where her surgery had previously been performed. Patient 30's record contained no evidence that she was seen by a qualified medical provider and did not contain any evidence of a MSE.

On 6/3/14, the hospital policy, titled, "Compliance with EMTALA (Emergency Medical Treatment and Labor Act)," dated 6/11, read, "A MSE must be offered to any individual presenting for examination or treatment of an emergency medical condition."

On 6/3/14 at 4:40 pm, the Director of Risk Management reviewed Patient 30's record and acknowledged that the record did not contain any evidence of a MSE by a qualified medical provider.

2. On 6/3/14, Patient 13's record was reviewed. Patient 13 presented to the ED on 5/12/14 at 11:27 am with a complaint of chest pain. Patient 13's record indicated that she was seen by the Perinatologist O (subspecialty of obstetrics concerned with the care of the fetus and complicated, high-risk pregnancies) in the clinic and complained of chronic chest pain.

Perinatologist G sent Patient 13 immediately to the ED for evaluation. Patient 13's record contained a document, titled, "RME (Rapid Medical Evaluation) Provider Note," dated 5/12/14 at 11:55 am written by Physician Assistant (PA) J which read, "Referral from OB r/o (rule out) cardiac/daily CP (chest pain)/lt (left) arm radiculopathy (damage or disturbance of nerve function) - Perinatologist G requests enzymes/eval via conversation at 1200. Eval /Tx (Evaluate/Treat)." Patient 13's record contained a triage assessment of "3" (Patients who need urgent treatment - who do not have immediately life-threatening illnesses or injuries.) Patient 13's record did not contain any evidence of MSE that included history and physical examination, description of the nature of her pain, nor any information related to her pregnancy. Patient 13's record indicated that nursing conducted an initial evaluation at 11:30 am and no other assessments or nursing information was documented.

Patient 13's record contained a dictated note at 2:29 pm (approximately three hours after arrival) by ED Physician A indicated that she told nursing she was unable to examine the patient because Patient 13 left the ED in order to pick up her daughter from school. ED Physician A noted "This is a borderline EKG (electrocardiogram - evaluates that heart rhythm).

On 6/4/14, the hospital policy, titled, "Compliance with EMTALA (Emergency Medical Treatment and Labor Act)," dated 6/11, read, "The examination must be the same appropriate screening examination that would be performed on any individual with similar signs and symptoms, regardless of the individual's ability to pay for medical care."

On 6/5/14 at 9 am, PA F was interviewed regarding Patient 13. PA F stated the RME was not a medical screen examination but more of a triage evaluation for if the physician needs to evaluate the patient or not. PA F stated "laying on of the hands" was part of the role. When asked what that meant, PA F stated that he would assess the patient's distress and perform an appropriate assessment. When asked what was an appropriate physical examination for a patient with chest pain would include, he stated "Heart and lung evaluation." PA F was asked if recording his decision making was part of his role and acknowledged that it was. PA F further acknowledged that Patient 13's record did not contain a record of his decision making or the elements of a MSE appropriate for chest pain. PA F further acknowledged that the record did not reflect information regarding the status of Patient 13's pregnancy.

According to the Journal of Perinatal Neonatal Nursing article, titled, "Assessment and evaluation of Women with Cardiac Disease during Pregnancy," dated 2006 Oct-Nov;20(4):295-302, "Maternal heart disease complicates 0.2 to 3% (percent) of pregnancies and is responsible for 10% to 25% of maternal deaths. Many healthy women manifest subtle signs of cardiac failure during uncomplicated pregnancy and birth. Classic symptoms of heart disease mimic common symptoms of late pregnancy, such as palpitations (heart pounding or racing), shortness of breath with exertion, and occasional chest pain...Detailed assessment of the woman throughout pregnancy may lead to initial discovery of heart disease."

3. On 6/3/14, Patient 14's record was reviewed. Patient 14 presented to the OB department on 3/15/14 at 6 pm with concerns regarding no fetal movement since the previous evening. Patient 14's record did not contain evidence of elements of the MSE including the EDC (estimated date of confinement (due date), an assessment of pain, or the results of a vaginal examination.

On 6/4/14, the hospital policy, titled, "OB Medical Screening Exam," dated 9/2013, read "All patients 20 weeks and greater gestation (pregnant) who present to the Labor and Delivery (OB),...for unscheduled exams or procedures will receive an OB Medical Screening Exam (MSE) by a qualified medical personnel." The procedure listed the following as elements of the medical screening exam...
2) Calculate EDC ...
3) ..Assess pain ...
9) Perform vaginal examination, as indicated ....

On 6/4/14 at 11:08 am, the Director of Perinatal Services (DPS) reviewed Patient 14's record and acknowledged that a vaginal exam was indicated. DPS further acknowledged Patient 14's record did not include all of the elements of a medical screening examination as required by the hospital policy.

Based on interview and record review, the hospital failed to ensure that seven of 10 sampled emergency department (ED) patients (Patients 7, 8, 9, 10, 11, 15, and 16) who required transfer to a higher level of care for an Emergent Medical Condition (EMC) met the requirements for an appropriate transfer as follows:

1. Patients 7, 8, 9 and 10's "Physician Certification" emergency transfer form was not properly authenticated with a date and time of the physician's signature.

2. Patients 7, 8, 9, 10, 11, 15, and 16's, "Physician Certification" did not contain:
* A description of the higher level of medical services that would cause the patient to benefit from the transfer,
* The medical benefits reasonably expected from the provision of the medical services available at the receiving facility, and that those benefits outweigh the increased risks to the individual from being transferred, and
* A summary of the risks and benefits upon which the certification was based.

3. Patients 7, 8, and 10's, "Physician Certification" form contained information that indicated the patients had been transferred using non-qualified personnel and transfer equipment

These failures have the potential for patients to have delays in receiving needed care and inappropriate transfers to another facility which could result in adverse outcomes including death.


Findings:

1. On 6/4/14, the record of Patient 7 was reviewed. Patient 7 was seen in the ED on 5/7/14 beginning at 7:37 pm with an initial complaint that she had thoughts of harming herself. In the ED, a Medical Screening Examination (MSE) showed Patient 7 did have an emergency medical condition and was at risk of harming herself. Patient 7 had previously been found unable to care for herself and placed under conservatorship. Patient 7's conservator was contacted and arrangements were made to transfer Patient 7 to a psychiatric care facility.

On 5/9/14 at or near 9:50 am, Patient 7 was transferred to the psychiatric facility for definitive care. Patient 7's record contains a "Physician Certification (for Emergent Transfer)" which was signed but not otherwise authenticated with a date or time of the signature. The certificate had only limited information about the services to be provided, the benefits to be received, the risks of transfer or the relationship between risks and benefits.

The certificate notes Patient 7 was transferred ("Mode of Transfer") by "Private Car" and the first and last name of an individual was listed. There was no notation that the listed individual was a family member or otherwise affiliated.

2. On 6/4/14, the record of Patient 8 was reviewed. Patient 8 was brought to the ED on 5/2/14 at 10:43 am by local law enforcement officers with the history of threatening others and himself. In the ED, a MSE of Patient 9 showed he did have an emergency medical condition and was at risk of harming himself and others. Because of this, Patient 8 was placed on involuntary psychiatric hold (5150) and plans were made to transfer him to psychiatric care specialty facility in a distant community.

At 4:55 pm on 5/2/14, Patient 8 was transferred to the distant psychiatric care facility. Patient 8?s record contains a "Physician Certification" which was signed but not otherwise authenticated with a date or time of the signature. The certificate had only limited information about the services to be provided, the benefits to be received, the risks of transfer or the relationship between risks and benefits.

The certificate noted Patient 8 was transferred ("Mode of Transfer") by "Private Car" and the first name of an individual is listed. There was no notation that the listed individual was a family member or otherwise affiliated.

3. On 6/4/14, the record of Patient 9 was reviewed. Patient 9 was seen in the ED on 5/3/14 beginning at 2:47 pm with an initial complaint that she thought she had had a seizure. Patient 9's MSE found that she did have a EMC and arrangements were made to send her to a medical center and physician where she had recently had some neurological (pertaining to nerves) specialty care.

At 4:55 pm on 5/3/14, Patient 9 was transferred to be admitted by her neurologist (Physician specializing in nerve function) at a local medical center. Patient 9's record contains a "Physician Certification" which was signed but not otherwise authenticated with a date or time of the signature. The certificate had only limited information about the services to be provided, the benefits to be received, the risks of transfer or the relationship between risks and benefits.

4. On 6/4/14, the record of Patient 10 was reviewed. Patient 10 was brought to the ED on 5/4/14 at 1:38 am by local law enforcement officers with the history of being "paranoid" (a mental condition in which one falsely believes others are trying harm them). Patient 10's MSE was not clearly delineated but concludes with "Medically cleared and given (two medications) will be released and clearing her to a 5150." The phrase "5150" refers to a state legislative statute regarding patients that need to be involuntarily held for psychiatric care because they are a danger to themselves or others. The record does not otherwise specify the reason for transfer or other specifics related to the care to be received at the receiving facility.

At 11:26 pm on 5/4/14, Patient 10 was transferred to the distant psychiatric care facility. Patient 10's record contains a "Physician Certification" which was signed but not otherwise authenticated with a date or time of the signature. The certificate had only limited information about the services to be provided, the benefits to be received, the risks of transfer or the relationship between risks and benefits.

The certificate notes the patient was transferred ("Mode of Transfer") by "Private Car" and the first name of an individual was listed. There is no notation that the listed individual was a family member or otherwise affiliated.





26611

5. A review of Patient 11's record indicated she was seen in the ED on 5/11/14 beginning at 3:15 pm with an initial complaint of abdominal pain following a VP shunt surgery. Ventriculoperitoneal shunting is surgery to treat excess cerebrospinal fluid (CSF) in the brain (hydrocephalus). Patient 11's surgeon was contacted and requested a transfer to a higher level of care for evaluation. Patient 11's record contained a "Physician Certification" for transfer that did not contain the reasons for transfer and was not signed by Patient 11 but instead signed by the physician. Patient 11's record indicated that she was alert and oriented and did not have conditions which precluded her from signing the transfer form. Patient 11's record also indicated that she had a family member present in the ED that could have signed for Patient 11 if she was unable to do so.

6. On 6/3/14, Patient 15's record was reviewed. Patient 15 was seen in the OB (obstetrical - for birthing) unit and found to have pre-eclampsia (a dangerous condition involving high blood pressure to both the mother and the fetus). Patient 15's physician provided stabilizing treatment and arranged for transfer to a hospital with a higher level of care. Patient 15's record contained a "Physician Certification" that did not include a detailed summary of the risks and benefits of the transfer.

7. On 6/3/14, Patient 16's record was reviewed. Patient 16 was admitted on 1/18/14 in labor. Patient 16 had been scheduled for a Cesarean section (delivery of the infant via the abdomen) at a hospital with a higher level of care on 1/23/14 due to fetal omphalocele (a high risk condition in which the stomach and other organs are on the outside of the body). Patient 16's physician provided stabilizing treatment and arranged for transfer to the hospital above. Patient 16's record contained a "Physician Certification" that did not include a detailed summary of the risks and benefits of the transfer.

On 6/4/14, the hospital's policy, titled, "EMTALA - Emergency Medical Treatment and Labor Act," dated 7/7/11, was reviewed. The policy instructed the physician to complete the certification form but did not detail the required elements of a complete physician certification.

On 6/4/14 between 9:45 and 10:30 am, Patients 7, 8, 9, 10, 11, 15, and 16 were concurrently reviewed with the hospital's Vice-President of Medical Affairs (VPMA), and he acknowledged and concurred with the findings listed above.

VPMA also provided information about the two individuals that provided the transfer transportation for Patients 7, 8 and 10. VPMA indicated these drivers were provided by a local mental-health care organization with which the hospital has an agreement. This agreement or "memorandum of agreement" (MOU) was obtained and reviewed. The MOU did not provide any information about the transfer services outlined above or the drivers that the organization provided. The agreement did not have language that specified the mental-health care organization would ensure the provision of services that would allow the hospital to be in compliance with any regulations. The VPMA stated that the hospital had no information to show that these drivers had received any specific training, were bonded or had other qualifications that would indicate they could provide appropriate and safe transportation for mental patients and/or patients that could be a danger to themselves or others. The VPMA indicated that he understood the hospital was responsible for ensuring that emergent transfer services and all services provided by agreement are safe and effective.