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Based on record review and interview the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires that hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by:

1) Failing to maintain an accurate and complete Emergency Department Central (patient) Log on each individual who came to the Emergency Department as evidenced by failing to document in the log the final disposition of patients who were remaining in the Emergency Department after 12:00 a.m. (see findings at A2405), and;

2) Failing to accept an appropriate emergency patient transfer request for which the hospital had the capacity and specialized capability to treat as evidenced by requesting the patient's payor source and requesting the transferring hospital call other hospitals for acceptance of the patient (see findings at A2411).

Based on Emergency Department record reviews, Emergency Department Central Log review and staff interviews, the hospital failed to maintain an accurate and complete central (patient) log on each individual who came to the Emergency Department as evidenced by failing to document in the log the final disposition of patients who were remaining in the Emergency Department after 12:00 a.m.
Findings:

Review of the hospital policy titled, Emergency Department Log, Number ED-E1, revised date of 04/08, provided by S1Regulatory Coordinator as current policy, revealed the following: Purpose: A coding and network system for patient demographic information. Policy: 1. A control register computer log, identified as the Emergency Department Log, is continuously maintained. The patient data is entered into the computer system by the registration clerk. 2. Performed by A. Emergency Department Clerical Staff B. [hospital] Business Services Clerical Staff.
Procedure: 1. The Emergency Department Log is computerized. Hard copies of the log are kept in the Administrative office of the Emergency Department for at least 5 years. The computer system in Emergency allows ED personnel to access the date of the last Emergency visit of patient. The past medical record can be obtained 24 hours a day from Medical Records. 2. Equipment: Emergency Department Log.

Patient #2
Review of the ED (Emergency Department) medical record for Patient #2, dated 7/17/13, revealed the patient was 35 year old female seen in the ED for blurred vision in both eyes. Her diagnosis was open angle glaucoma and she was transferred to Hospital A on 7/17/13 at 3:20 p.m.

Review of the Emergency Room Log for 7/17/13 for the main campus of the hospital revealed the patient had an unassigned ED physician.

Patient #4
Review of the ED (Emergency Department) medical record, dated 7/14/13, revealed Patient #4 was a 48 year old male with Schizophrenia experiencing suicidal and homicidal thoughts. He was transferred on 7/15/13 to a Behavioral Hospital.

Review of the Emergency Room log for 7/14/13 for the main campus of the hospital revealed Patient #4 had an unassigned ED physician. Review of the Emergency Log for 7/15/13 revealed no information on Patient #4.

Patient #8
Review of the ED medical record, dated 7/15/13, revealed Patient #8 was a 57 year old male who presented to the ED at 9:41 a.m. with a chief complaint of suicidal thoughts. The ED record revealed the patient was admitted to the hospital's behavioral health unit on 7/15/13 at 4:02 p.m.

Review of the Emergency Room Central Log for 7/15/13 for the main campus of the hospital revealed Patient #8 had an unassigned ED physician. There was no documented evidence on the ED log that the patient was admitted to the hospital, nor was there any evidence of the final disposition of Patient #8.

An interview was conducted on 8/12/13 at 10:00 a.m. with S32 Director of Admissions/Registration. She stated the statement, "ER Physician Unassigned" on the Emergency Room Log meant the patient left without being seen. She also stated the Emergency Room Log is printed every night at midnight.

An interview was conducted on 8/12/13 at 1:05 p.m. with S8 RN Clinical Informatics. With review of the Electronic Emergency Room Log, he reported he was unable to pull up the log electronically. Every night at midnight the system would print the Emergency Room Log and the log would be placed in a binder. The patients that are in the Emergency Room at midnight when the log is printed, their disposition in the log reads the patient had an unassigned emergency physician, which indicates the patient left without being seen. There is no process in place to capture those patients' disposition. He went on to report he could work on pulling information from different programs to obtained a completed emergency room log for the surveyors, but currently there is not one program that can provide the dispositions of all the emergency room patients.

Review of the Emergency Room Log for the offsite campus of the hospital for 7/13/13 revealed out of 111 patients entered into the Emergency Room log, 38 patients were listed as leaving before being seen. This would mean 34 % of the patients left the ED without being seen on 7/13/13.

Review of the Emergency Room Log for the main campus of the hospital for 7/13/13 revealed out of 128 patients entered into the Emergency Room log, 55 patients were listed as leaving before being seen. This would mean 42.9 % of the patients left the ED without being seen on 7/13/13.


An interview was conducted with S2 Director of Quality and Patient Safety on 8/12/13 at 2:00 p.m. She confirmed the Emergency Room Log was incomplete and lacked a large number of patients' dispositions and the hospital would start immediately to correct the problem.

On 8/13/13 at 8:30 a.m. a completed Emergency Room Log for the months of June and July 2013 were given to the surveyors, one day after the initiation of the complaint investigation. The initial request for the an Emergency Department Log was for the last 6 to 12 months. These two months were the only completed Emergency Room Logs that were provided to the surveyors by the hospital during the investigation.



17091

Based on review of policy and procedures and interviews the hospital failed to accept an appropriate emergency patient transfer request for which the hospital had the capacity and specialized capability to treat as evidenced by requesting the patient's payor source and requesting the transferring hospital call other hospitals for acceptance of the patient (Patient #43).
Findings:

Review of the hospital policy titled, Acceptance of Transfer Patients with Emergency Medical Conditions, Number RI-105, revised date of 11/12 and provided as current policy by S1 Regulatory Coordinator revealed in part the following: Purpose: To outline the guidelines for receipt of patients transferred with emergency medical conditions. It is the policy of [hospital] to accept patients for inter-hospital emergency transfer from within the boundaries of the United States who are suffering from emergency medical conditions that are in need of stabilizing treatment that is within the capabilities and capacity of this facility but not available at the original facility treating the patient. Such acceptance will be without regard to the financial ability or method of payment of the patient, or the race, creed, color, national origin, sex, sexual preference, or condition of disability of the patient to the extent that such disability is not a decisive medical factor in the ability of this hospital to care for the patient....
Emergency Medical Condition: A patient is considered to have an emergency medical condition if the treating physician at the transferring facility determines that the patient is suffering from an emergency medical condition.
Procedure: All requests for transfer and acceptance of patients with an emergency medical condition will be directed to the House Supervisor to determine if the facility has the capacity and capability to accept the transfer....2. No inter-hospital emergency transfer may be refused unless one of the following conditions is met: a. The hospital does not have coverage for the requested specialized service at the time of request. b. The hospital/applicable department is at capacity....c. It is determined, in consultation with referring facility, that there is no need for the specialized services available at [hospital].
5. All requests for transfers of patient with emergency medical conditions received by [hospital] that are not accepted for any reason will be documented on the Emergency Transfer Analysis Form and forwarded to the house supervisor who will then forward to Corporate Compliance....

Review of the emergency department medical record from Hospital B for Patient #43 revealed the patient was a 32 year old male who presented to the emergency department (ED) of Hospital B on 07/13/13 at 7:48 a.m. with complaints of facial swelling after a new medication was started the day before. Further review of the chief complaint revealed the patient had been seen in the ED of Hospital B 4 times since 07/03/13 for Hypertension and symptomatic Anemia secondary to an upper Gastro-Intestinal (GI) Bleed.

Review of the ED physician documentation from Hospital B revealed on 07/13/13 at 11:52 a.m. the physician documented the patient's condition was, "Critically ill, life threatening." The physician's diagnoses were documented as follows: Malignant Hypertension, Congestive Heart Failure, Hyperlipidemia, Diabetes Mellitus, Gastropareses, Anemia, GI Bleed, Renal Disease from Hypertension, Renal Failure, Hypoalbuminemia, Allergic Reaction to Medication, Hypokalemia, History of Medical Non-Compliance, Nausea and Vomiting, and Hematuria.
Further review of the physician's documentation revealed the following entry at 12:22 p.m.: "Family initially requested a transfer to City A, ("anywhere but Hospital A"). Tried [hospital] but they do not accept LAcare (Medicaid Managed Care Plan). The family will sign AMA (Against Medical Advice) and transport him in a private vehicle to the ER (Emergency Room) in City B. Strongly advised against that, but family very determined to sign AMA."
The ED physician documentation revealed the following entry at 1:03 p.m.: "Status: worsened. Family changed their mind and request an ambulance transfer to Hospital A."

Review of the Nursing Notes from Hospital B ED revealed the following:
"07/13/13 at 11:59 a.m. Spoke with S10RN House Supervisor at [hospital] main campus re transfer, requested that a face sheet be faxed to ___ (fax number) and she will call us back.
12:16 p.m. S10RN House Supervisor at [hospital] main campus called back and stated that they do not accept Medicaid LAcare."
Further review of the Nursing Notes revealed the House Supervisor at Hospital A was contacted regarding the transfer of the patient, and Hospital A accepted the patient at 12:51 p.m. The Nursing Notes also revealed the patient's mother would not sign the AMA because she knew how sick the patient was and wanted him transferred. The Nursing Notes revealed the patient was transferred by ambulance to Hospital A at 2:41 p.m.

Review of the Transfer Form from Hospital B revealed the service the patient needed was Gastroenterology and the reason for transfer was, "Transfer is medically indicated-Malignant Hypertension, Congestive Heart Failure, Renal Failure." The Transfer Form revealed the patient's condition on transfer was stable.

On 08/12/13 at 12:50 p.m., the Emergency Transfer Analysis records for July, 2013 were requested for review. At 1:30 p.m., S1Regulatory Coordinator provided 1 Emergency Transfer Analysis form dated 06/21/13 and stated there were none for the month of July 2013. Review of the Emergency Transfer Analysis form dated 06/21/13 revealed the transfer was denied due to Ophthalmology services were not available at the hospital.

On 08/14/13 at 9:05 a.m., S10RN House Supervisor was interviewed with S2Director of Quality & Patient Safety present for the interview as requested by S10RN House Supervisor. S10RN House Supervisor was asked to explain her role in the transfer/acceptance of ED to ED transfers. S10RN House Supervisor stated the call comes in for the House Supervisor and it was her (House Supervisor) decision whether to accept or deny a transfer. S10RN House Supervisor stated the only reason to deny a transfer is if an ICU (Intensive Care Unit) bed is needed and is not available. S10RN House Supervisor stated, "I have never denied a transfer." S10RN House Supervisor stated she had been in her position as House Supervisor since mid-June when she completed her orientation. She stated she was not aware of any payer source that was not accepted by the hospital. S10RN House Supervisor stated she requested a face sheet from the transferring hospital on in-patient transfers and then stated, "If it is an emergency department transfer I know I am not supposed to ask for a face sheet." S10RN House Supervisor then stated there was an incident where she asked for a face sheet on an ED transfer. "I know the patient was in the ER, but the way it was explained by the nurse I was thinking it was a direct admit." S10RN House Supervisor stated this ED transfer was from Hospital B on July 13, 2013. She stated the call came in and the nurse from Hospital B stated, "I have a patient here, he's a 'frequent flyer' with multi-system problems. He comes in and we send him somewhere." S10RN House Supervisor stated she told the nurse at Hospital B she would call her back and in the meantime to fax her a face sheet on the patient. S10RN House Supervisor stated before she ended the phone call, she asked if the patient was emergent and the nurse from Hospital B said no, he was stable. S10RN House Supervisor stated she looked at the census on the floor where the patient would have been admitted to, the staffing for the next shift, checked with the staffer at the off-site campus, and the "bed board" in the ED and determined that the hospital had the capacity and, "felt we could accept the patient." S10RN House Supervisor stated she then looked at the faxed face sheet from Hospital B, "Not thinking ER to ER" and called admissions. She stated admissions informed her the patient had LAcare and the hospital did not accept this insurance. S10RN House Supervisor stated she called Hospital B back and told them they did not accept this insurance and asked the nurse if she had tried other hospitals and they had not accepted. S10RN House Supervisor stated the nurse at Hospital B told her she had not tried any other hospitals and stated that she would try. S10RN House Supervisor stated she told the nurse at Hospital B to call her back. S10RN House Supervisor stated she did not call her back so she called Hospital B back twice and was informed on the last call that the patient was transferred to Hospital A. S10RN House Supervisor stated in her mind she was not refusing the patient and the patient was an in-house transfer. S10RN House Supervisor verified she knew the patient did not have an accepting physician and the patient was an ED patient. She stated she did not remember the reason for the transfer, but dialysis came to her mind. She stated dialysis was available at the hospital. S10RN House Supervisor stated she felt the [hospital] could provide the services this patient needed. S10RN House Supervisor verified the process of asking the transferring hospital if they had tried other hospitals before accepting the patient was not hospital procedure. When asked if she had received training on transfers, S10RN House Supervisor stated, "We did go over in-house and ER transfers, I just got confused on this call." S10RN House Supervisor stated she had done an on-line EMTALA training, "but it did not sink in, it was not in my head that day (07/13/13)." S10RN House Supervisor also verified it was the responsibility of the House Supervisor to ask enough questions to determine if the transfer request was an ER to ER transfer or an in-patient transfer. During this interview, S2Director of Quality & Patient Safety reviewed the hospital's on-call schedule for 07/13/13 and verified the hospital had a Gastro-Intestinal physician on call. S2Director of Quality & Patient Safety stated, "We did not feel this was an EMTALA violation because the patient was stable."

On 08/14/13 at 9:50 a.m., S1Regulatory Coordinator provided the Patient Care Services 24-hour Summary Report for 07/13/13. Review of the report revealed the hospital was not at full capacity and had beds available in the inpatient units and intensive care unit. The report revealed the total number of acute beds was 238 and only 88 were occupied. S1Regulatory Coordinator verified the hospital could have accepted transfers on 07/13/13.