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Based on review of hospital policies/procedures, hospital documents, medical record review and staff interviews it was determined the hospital failed to enforce policies/procedures that comply with the requirements of 42 CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases, for a patient that was transferred by ambulance from a nursing home to the ED for emergency treatment.

Findings include:

A2405 489.20 (r)(3) Emergency Department (ED) Log:
Patient #4 (target patient) was not documented in the Critical Access Hospital (CAH) ED central log.

A2403 489.24 (b) Medical Record:
A medical record was not generated for Patient #4.

A2406 489.24(a) Medical Screening Exam (MSE):
Patient #4 was not provided with a MSE prior to transfer to another acute care facility

A2407 489.24(d)(1)(i) Stabilizing Treatment:
Patient #4 was not provided documentation of stabilization treatment prior to transfer to another acute care facility.

A2409 489.24(d)(1)(ii). Appropriate Transfer:
Patient #'s 2, 3, 5, 8, 9, 11, 14, 17, 18, 20, 23, 24, and 25 were transferred to another facility with incomplete Patient Transfer Forms.

Based on review of hospital policies/procedures, documents, and interviews, it was determined that the hospital failed to generate and retain a medical record for Patient #4, (target patient) after the patient's arrival to the emergency department (ED).

Findings include:

Hospital policy titled "EMTALA Guidelines Policy #HW1025" requires: "...Medical and other records...will be maintained in accordance with Hospital record-retention policies, but not less than five years...."

Documentation of Patient #4's ED visit consists of the hospitals Emergency Medical Services Telemetry Form completed by RN #7 and the Tri-City Fire Department Ambulance encounter form, completed by the transporting EMT and Paramedic.

The hospital EMS Telemetry form dated 08/23/13 at 1226 hours revealed: "...Chief complaint stroke alert since yesterday...change in medication...non responsive, left droop...Past history stroke, no allergies...vital signs...oxygen level 88%...dextrose stick 123...Physical Findings: Narcan no response...Intravenous X 2...Physician Orders: Physician #1 flew patient after arrival...."
The form is signed by both RN #7 and Physician #1.

The Director of ED confirmed during an interview conducted 09/05/13, that the Emergency form is used by the ED nursing staff as a written report from the ambulance crews, who telephone the facility to update the ED of the patient's condition prior to arrival.

The Tri-City ambulance encounter form dated 08/23/13 revealed: "...the ambulance left the nursing home at 1228 hours; arriving at the hospital with the patient at 1239 hours...."

The Paramedic transferring the patient confirmed during a telephone interview conducted 09/05/13, at 1330 hours, that he talked with the nurse via telephone prior to arrival. After arrival to the ED, the Paramedic talked directly to Physician #1 regarding flying the patient to another facility via helicopter. The physician agreed with the transfer; the helicopter was called by the local the fire department; and the patient was flown to the receiving hospital.

The Director of Quality confirmed the following during an interviews conducted on 09/05/13: Patient #4 arrived by ambulance to the ED and was placed in the hallway of the CAH because there were no empty beds; and Patient #4 was transferred to another acute care facility prior to receiving an appropriate MSE.

Based on review of hospital policies/procedures, documents and interviews, it was determined that the hospital failed to require that a patient transferred from a nursing home to the CAH on 08/23/13, was included in the hospital ED Log (Patient #4).

Findings include:

Hospital policy titled "EMTALA Guidelines Policy #HW1025" requires: "...Registration Log means a log maintained by the Hospital on each individual who comes to its dedicated emergency department (s) or any location on the Hospital property seeking emergency assistance and the disposition of each individual...."

Review of the ED log dated 08/23/13, revealed no entry for Patient #4, who was transferred to the facility on 08/23/13.

The Director of Quality, and the Director of the Emergency Department confirmed during interviews conducted on 09/05/13, that Patient #4 was not included in the ED Log.

Based on review of hospital policies/procedures and interviews, it was determined that the hospital failed to provide a Medical Screening Exam for Patient #4 (target patient), after the patients arrival to the emergency department (ED).

Findings include:

Hospital policy titled "EMTALA Guidelines Policy #HW1025" requires: "...will provide emergency services and care...EMTALA is applicable to any physician who is responsible for the examination, treatment, or transfer of an individual whom EMTALA applies...the process required to...determined whether or not an emergency medical condition exists...."

Patient #4 did not have a medical record that confirmed any triage, assessments, presenting signs and symptoms, history/physical or monitoring by a physician or other qualified medical personnel.


The Director of Quality confirmed during an interview conducted on 09/05/13, that Patient #4 arrived by ambulance to the ED, and was placed in the hallway of the CAH.

The ED Director confirmed there was no documentation of a MSE for the patient; and the patient was transferred to another acute care facility prior to receiving an appropriate MSE.

Based on review of hospital policies/procedures and staff interviews, it was determined that the hospital failed to require that a patient that was transferred to another acute care facility on 08/23/13, received stabilization treatment prior to the transfer (Patient #4).

Findings include:


Hospital policy titled "EMTALA Guidelines Policy #HW1025" requires: "...Stable for Transfer means an individual has an emergency medical condition that is not resolved, but (i) the treating physician has determined, with reasonable clinical confidence, that the individual is expected to leave the Hospital and be received at the second facility, with no material deterioration in his/her medical condition...."

Patient #4 was transferred from a nursing home on 08/23/13, to the CAH for altered level of consciousness, left sided weakness, and facial droop. The patient was then transferred to another facility the same day.

The patient did not have a medical record that confirmed any treatments, medications, surgeries, or other services given to stabilize the patient prior to transfer to another acute care facility. Patient #4 did not have a medical record that confirmed the patient's mental status evaluation, diagnosis, history/physical, or any diagnostic tests.

The Director of Quality, and the Director of the Emergency Department confirmed during interviews conducted on 09/05/13, that Patient #4 was received by the hospital; and transferred to another acute care facility without stabilization treatment.

Based on review of hospital policies/procedures, medical records of transported patients, and interviews, it was determined that the hospital failed to implement and enforce their transfer/EMTALA policies addressing documentation, confirming the appropriateness of patients' assessments, care, treatment, and transfers.

Findings include:

The Patient Transfer Form, requires: "...Patient transfer may not take place until each of the following is accomplished...To be completed by the Transferring Physician or a Qualified Medical Person" (as follows):

Diagnosis
Risks
Benefits
accepting physician's agreement
receiving facility
mode of transport
Signature of Physician/Qualified Medical Person
verification receiving facility has space to receive the patient
receiving facility's accepting nurse
verification the sending hospital has provided a verbal report
"copies of the appropriate medical record"
Signature of Transferring Nurse
patient/representative's Consent/Refusal for transfer
Signature of Patient/Legal Representative.

The ED Medical Director, Quality Manager RN, and the RN ED Director all stated during interviews conducted on 09/06/13, that the Patient Transfer Form is the designated area in the medical record for recording Transfer information.

Thirteen (13) of 13 medical records' Patient Transfer Forms were incomplete, and did not include all required information not otherwise documented in the medical records; Patient #'s 2, 3, 5, 8, 9, 11, 14, 17, 18, 20, 23, 24, and 25.

The Quality Manager RN, and the RN ED Director both confirmed during interviews conducted on 09/06/13, that the Patient Transfer Forms were incomplete. The forms and/or medical records did not include all the above listed documentation required to verify an appropriate transfer.

The Quality Manager RN further confirmed that the hospital did not include EMTALA documentation requirements as part of their Quality processes, did not audit transferred patients' records to ensure compliance with hospital policies and/or EMTALA regulations, and did not identify/address staff/physician deficient practices in ensuring all transfers were identified and appropriately documented.