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Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure signage specifying the rights of individuals to an examination and treatment of emergency medical conditions and women in labor who come to the Emergency Department for health care services were conspicuously posted at entrances, admitting area, waiting room and treatment areas in the facility's Emergency Department (ED) as required under section 1867 of the Social Security Act.

Findings include:

Review on January 12, 2015, of the facility's "EMTALA System Policy", last reviewed October 17, 2014, revealed "... Patient Transfer and Emergency Medical Treatment and Labor Act (EMTALA) Purpose: To identify guidelines for providing the appropriate setting for conducting medical screening examinations; to identify providers eligible to perform emergency medical screening examinations; To comply with the Emergency Medical Treatment and Labor Act EMTALA), 42 U.S.C. 1395 and subsequent federal interpretive guidelines and state regulations. ... Definitions: ... Emergency Medical Treatment and Labor Act EMTALA refers to Sections 1866 and 1867 of the Social Security Act, 42 U.S.C. and 1395dd, which obligates hospitals to provide medical screening, treatment and transfer of individuals with emergency medical conditions or women in labor. It is also referred to as the "anti-dumping" statute and COBRA (Consolidated, Omnibus Budget and Reconciliation Act). ..."

Observation on January 12, 2015, of the facility's ED revealed no signage in the ED ambulance entrance, the ambulatory entrance, the admitting area or at the registration desk specifying the rights of individuals to examination and treatment of emergency medical conditions and women in labor. Further observation revealed one sign measuring approximately 12 inches by 14 inches hanging approximately six inches from the ceiling over a wheelchair accessible height phone in the waiting area.

Interview with EMP1, EMP3 and EMP4 on January 12, 2015, at approximately 10:45 AM confirmed the required signage specifying the rights of individuals to an examination and treatment of emergency medical conditions and women in labor was not placed in a conspicuous manner in the ED ambulance entrance, the ambulatory entrance, the admitting area or at the registration desk to be noticed by all who enter the ED or those waiting in the waiting area. Further interview with EMP1, EMP3 and EMP4 confirmed the signage addressing the rights of individuals to an examination and treatment of emergency medical conditions and a woman in labor measured approximately 12 inches by 14 inches and was hanging approximately six inches from the ceiling over a wheelchair accessible height phone in the waiting area.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to maintain a central log on each individual presenting to the Emergency Department (PT1).

Findings include:

Review on January 12, 2015, of facility policy "EMTALA System Policy," last reviewed October 17, 2014, revealed "Patient Transfer and Emergency Medical Treatment and Labor Act (EMTALA) Purpose: To identify guidelines for providing the appropriate setting for conducting medical screening examinations; to identify providers eligible to perform emergency medical screening examinations; To comply with the Emergency Medical Treatment and Labor Act EMTALA), 42 U.S.C. 1395 and subsequent federal interpretive guidelines and state regulations. Departments that conduct medical screenings include: Emergency Departments of GMC ... Definitions: ... Emergency Medical Care Log is in the Geisinger's electronic health record which is maintained on all individuals who present to the emergency department seeking medical care. The log shall be kept for five years and contain specific patient information including: Patient identification, Medical record and encounter number, Patient type, Presentation time, Provider evaluation note, Discharge time, Disposition categorized as treated and released, admitted, discharged, transferred, or refusal of treatment. ..."

Interview on January 12, 2015, at 9:30 AM with EMP2 revealed there were 30 patients in the Emergency Department (ED) waiting room on the afternoon of December 29, 2014. It was taking an average of one hour for patients to be triaged. The following information was reported to EMP2: Two police officers brought PT1 through the ambulance entrance and to the control desk, as a 302 commitment. EMP6 suggested the police officers take PT1 to another hospital.

EMP2 stated the hospital who received PT1 contacted EMP2 on December 30, 2014, stating they received a patient from Geisinger Medical Center on December 29, 2014, without proper notification or transfer forms. EMP2 stated this event was discussed with EMP6, and the event was confirmed.

Interview on January 12, 2015, at 11:27 AM with EMP5 confirmed they spoke to EMP6 on January 10, 2015, regarding PT1, a 302 mental health patient, noting the following event: There was an increased patient volume in the ED on December 29, 2014. EMP6 saw two police officers come in the ambulance entrance with a patient. EMP6 told the officers and patient there would be a long wait at Geisinger Medical Center, and they might get seen quicker at another hospital.

EMP6 was working on the day of the investigation, January 12, 2015, and refused to speak with the survey team.

Review of the Central Log for the Emergency Department (ED) for December 29, 2014, revealed no documentation PT1 presented to the facility's ED.

Interview of EMP2, at 9:30 AM on January 12, 2015, confirmed PT1 was not listed on the Central Log for the Emergency Department (ED) for December 29, 2014.

Review on January 12, 2015, of the ED record for PT1 from the receiving hospital revealed the patient was brought in by police as a 302. The patient reported they were initially brought to Geisinger Medical Center Danville. While in the waiting room, PT1 was reportedly told there was no room for the patient, and PT1 was transferred to [the receiving hospital] to be evaluated. Following evaluation in the ED, PT1 was admitted to the receiving hospital.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure each patient presenting to the Emergency Department was provided with an appropriate medical screening examination by a qualified medical provider for PT1 and one of 28 medical records reviewed (MR22).

Findings include:

Review on January 12, 2015, of the facility policy "EMTALA System Policy," last reviewed October 17, 2014, revealed "Patient Transfer and Emergency Medical Treatment and Labor Act (EMTALA) Purpose: To identify guidelines for providing the appropriate setting for conducting medical screening examinations; to identify providers eligible to perform emergency medical screening examinations; To comply with the Emergency Medical Treatment and Labor Act EMTALA), 42 U.S.C. 1395 and subsequent federal interpretive guidelines and state regulations. Departments that conduct medical screenings include: Emergency Departments of GMC ... Policy: Any person who comes to facility requesting assistance for a potential emergency medical condition/emergency services will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists. Persons with emergency conditions will be treated and their condition stabilized without regard to ability to pay for services. EMTALA does not apply to inpatients. The triage process recognizes that triage and a medical screening are two separate processes. Definitions: Qualified Medical Provider to perform a medical screening examination within Geisinger facilities are as follows: Doctor of Medicine or Osteopathy Certified midwife with staff privileges at Geisinger Health System campuses that include obstetrical care Advanced practitioners as defined by the medical staff bylaws of the specific campuses of Geisinger Health System ... Procedure: A hospital must provide for an appropriate medical screening examination within the capability of the hospital emergency department to any individual who comes to the emergency department and requests examination of treatment. The purpose of this screening examination is to 'determine whether or not an emergency medical condition exists.' If an emergency medical condition exist [sic], then further medical treatment must be provided to stabilize the patient or the patient must be transferred to another facility in accordance with the policy. Requirements of a medical screening: The medical screening consists of an assessment and any ancillary testing or focused assessment based on the patient's chief complaint necessary to determine the presence or absence of an emergency medical condition. This may be a brief history and physical examination or may require complex ancillary studies and procedures such as, but not limited to, lab tests, fetal monitoring, EKG [electrocardiogram] tracing or radiology exam. The medical screening is the process a provider must use to reach with reasonable clinical confidence whether a medical emergency does or does not exist. The medical screening must provide evaluation and stabilizing treatment within the scope of the hospital or facility's abilities and not consider a patient's ability to pay for services. The medical record will reflect the findings of the medical screening including results of any tests performed and analysis. Disposition of the patient will be documented with any education provided and a follow-up plan of care if the disposition of discharge is appropriate. ..."

1) Interview on January 12, 2015, at 9:30 AM with EMP2 revealed there were 30 patients in the Emergency Department (ED) waiting room on the afternoon of December 29, 2014. It was taking an average of one hour for patients to be triaged. The following information was reported to EMP2: Two police officers brought PT1 through the ambulance entrance and to the control desk, as a 302 commitment. EMP6 suggested the police officers take PT1 to another hospital.

Review on January 12, 2015, revealed no medical record existed for PT1 for December 29, 2014. There was no documentation a medical screening examination was performed for PT1.

Interview on January 12, 2015, at 9:30 AM with EMP2 confirmed there was no medical record or documentation of a medical screening examination for PT1 for December 29, 2014.

Cross reference:
489.20(r)(3) Emergency Room Log


2) Review of MR22 on January 12, 2015, revealed the patient presented to the facility's ED at 5:25 PM on December 29, 2014, with the complaint of sharp stabbing pain in the left upper abdominal quadrant. MR22 rated the pain as 8/10 [Zero represents no pain at all while 10 represents the worst imaginable pain.] The admitting diagnosis was gastrointestinal (GI) bleed.

Review of MR22 on January 12, 2015, revealed nursing staff triaged the patient on December 29, 2014, at 5:26 PM and vital signs were obtained. An echocardiogram (ECG was completed. The nursing staff assigned MR22 a triage level of L2 (High Risk).

Continued review of MR22 on January 12, 2015, revealed physician documentation by EMP6 that the patient has a history of varices and GI bleeding, was sent here from [name of prison] for evaluation of possible GI bleed, patient without history of recent melena (black, tarry stool), patient in no distress, VS (vital signs) stable, EKG shows no ischemic changes, ED wait will be hours. Correctional officers will be able to take patient to [name of hospital] ED, patient stable for transfer, discussed with OTH5 at the receiving hospital [name of hospital].

There was no documentation in MR22 that EMP6 conducted a medical screening examination to determine if an emergency medical condition (MEC) existed.

Interview with EMP1 and EMP3 on January 12, 2015, at approximately 1:45 PM confirmed the above nursing triage of MR22 and physician documentation. EMP1 confirmed there was no documentation in MR22 that EMP6 conducted a medical screening examination.

Based on review of facility policies, medical records (MR) and interviews (EMP and OTH), it was determined the facility failed to notify the receiving facility of a patient transfer and failed to send all medical records related to the patient's condition for two of three medical records reviewed (MR30 and MR31).

Findings include:

Review of facility policy "EMTALA System Policy," last reviewed October 17, 2014, revealed "... Patient Transfer and Emergency Medical Treatment and Labor Act (EMTALA) Purpose: To identify guidelines for providing the appropriate setting for conducting medical screening examinations; to identify providers eligible to perform emergency medical screening examinations; To comply with the Emergency Medical Treatment and Labor Act EMTALA), 42 U.S.C. 1395 and subsequent federal interpretive guidelines and state regulations. ... Definitions: ... Emergency Medical Treatment and Labor Act EMTALA refers to Sections 1866 and 1867 of the Social Security Act, 42 U.S.C. and 1395dd, which obligates hospitals to provide medical screening, treatment and transfer of individuals with emergency medical conditions or women in labor. It is also referred to as the "anti-dumping" statute and COBRA (Consolidated, Omnibus Budget and Reconciliation Act). ... Transfer means the movement of a living patient to another facility at the direction of any person employed by the clinic or hospital, but does not include such a movement of an individual who has been declared dead or who leaves the facility against medical advice (AMA) or leaves without being seen (LWOBS). Procedure: ... Patient Transfers from Geisinger: Duties of the Geisinger Transferring Hospital: Physician will certify that the benefits of the transfer outweigh the risks which include written enumeration of the medical risks and benefits based on information at the time of transfer. Obtain the patient's informed consent. Arrange an appropriate transfer by providing treatment within the capacity of the hospital, arrange for acceptance by another facility, and transfer through qualified personnel and equipment. Transfer the medical record and copies of pertinent radiographic and laboratory findings to the receiving facility. Complete the GHS- Physician Certification for Transfer/Consent to Transfer and the Interhospital Transfer Forms A-490-026-FMRpb Rev/MRPC Approved: 12/13."

Review on January 30, 2015, of the Geisinger Medical Center's "Interhospital Transfer Form" revealed two sections, a section for the "Transferring Physician Information" and a section for the "Nursing Evaluation". The nursing evaluation section provided space for the nursing to document: Date of Transfer, Receiving Facility Name, Report given to, Vital signs at time of transfer, Allergies, Loc/Mental Status, Laboratory Studies, Copy of X-rays accompanying patient, Copies of Medical Records accompanying, Physician Certification for Transfer and Consent Form completed, Brief Patient Assessment Upon Transfer, Valuables accompanying patient and Mode of transportation.

Review of MR30 revealed this was an 18-year-old patient with a history of depression who presented for evaluation of suicidal ideation. The patient admitted to the ingestion of 15-20 ibuprofen (pain medication) pills 200 mg. about 4 hours prior to admission. A consultation was documented with Psychiatry who advised transfer to a psychiatric facility with available bed. Physician disposition revealed MR30 was signed out to CF4 and was awaiting possible transfer to another hospital. There was an ED physician addendum which noted the patient was signed out to me by OTH10 and the medical treatment to this point has been reviewed and the future plan of care has been discussed. The patient had bed found at [name of hospital] by delegate for transfer, however the delegate reports that patient cannot be accepted for the bed because the patient did not come through the [name of hospital] Emergency Department. Patient was discharged in the care of the mother, contracted for safety en route, with instruction to present to the [name of hospital] ED to be evaluated for psychiatric admission. This was the only workable solution as per delegate. Family and patient came to the physician desk and stood in front of me demanding to leave, would not go back to the room, stated they would be leaving to go to [name of hospital] ED whether I gave them any paperwork or not. The patient remained hemodynamically stable and had controlled pain while under my care in the ED. [e-signed by] CF4 on January 18, 2015, at 2216 and CF3 on January 23, 2015, at 1339.

The discharge instructions were included in MR30 for Depression and noted "You are being transferred to an outside psychiatric facility for continued care. Please go to the [name of hospital] ED to be admitted to the hospital."

Further review revealed MR30 contained the Geisinger Health System (GHS) - Physician Certification for Transfer/Consent to Transfer and the Interhospital Transfer Forms. The nursing evaluation portion of the form was not completed.

Review of MR31 revealed this 14-year-old presented with their mother and father for evaluation of depression and suicidal ideation. The ED physician spoke with the pediatric psychiatric attending, and there were no beds at Geisinger for an adolescent psychiatry patient. Delegate was called to begin a bed search for the patient. At 4:09 AM a bed was found at [name of hospital]. The family was instructed to transport the patient to the receiving hospital. The ED physician documented the receiving facility was aware. The ED physician disposition revealed the patient was transferred to [name of hospital]. The patient discharge instructions stated "Evaluation Psychiatric Patient made threats of wanting to take an overdose of medication. Unable to contract for safety with parents. Suicidal Thoughts [72-hour hold] ... With your protection and well-being in mind, you have been placed on a legal "72-hour hold" so that you can be evaluated by a psychiatrist." MR31 contained a 201 voluntary commitment form signed by the patient's father January 18, 2015. The facility was unable to provide documentation the GHS - Physician Certification for Transfer/Consent to Transfer and the Interhospital Transfer Forms were completed.

Interview with OTH10 at 12:10 PM on January 30, 2015, confirmed for a psychiatric patient the delegate completes the bed search, speaks to the receiving facility's physician for acceptance of the transfer, and completes the paperwork and informs the ED physician. There is no physician to physician phone call for a psychiatric patient. OTH10 noted they have worked in the ED for three years, and this is the facility's practice. OTH10 stated the delegate is there to facilitate the transfer or commitment of a psychiatric patient. For transfer of an acute care patient to another hospital, i.e., a burn patient to another acute care hospital, there would be no delegate, and in this type of a transfer, there would be a physician to physician phone call.

Interview with EMP1 on January 30, 2015, confirmed the "delegate" was the crisis worker. The crisis worker was not an employee of the hospital.

The following findings were obtained at the receiving hospital.

The medical record at the receiving hospital for MR30 was reviewed on January 30, 2015, at approximately 3:00 PM. The patient arrived at the receiving hospital ED at 11:09 PM on January 18, 2015, accompanied by the patient's mother. Documentation noted the patient took 15-20 Advil at 12 noon for suicide purposes. Documentation noted the patient was seen at Geisinger Medical Center for same issue and sent to the receiving hospital for placement.

Further review at the receiving hospital revealed the following information was received from Geisinger Medical Center for MR30: A physician exam/progress note completed at 9:50 PM on January 18, 2015, and discharge instructions. The discharge instructions stated the patient was being transferred to [name of hospital] emergency department for continued care. Additional review of the medical record at the receiving hospital revealed there were no Geisinger Medical Center transfer forms or a completed 201 commitment form from Geisinger Medical Center.

Interview on January 30, at 2:05 PM with OTH9 at the receiving hospital revealed when receiving a patient from another facility, a call is received in their behavioral health unit (BHU) on a bed search. Basic information is provided to the registered nurse (RN) in the BHU. The RN calls physician, and they discuss this basic information. The BHU then requests the sending facility to complete their "Fax Back Form" to provide the information necessary to review prior to accepting the patient. If the patient has been medically cleared in the ED at the sending hospital, there is no need for the patient to be seen in the receiving hospital's ED. Once the RN receives the information on the Fax Back Form, a call is placed to OTH9 who reviews. OTH9 then decides if the BHU can accept the patient, based on bed availability and the milieu in the unit.

Continued interview with OTH9 revealed MR30 came to the receiving hospital's ED in the middle of the night. At approximately 6:00 or 7:00 PM prior to MR30 presenting to the ED, OTH9 received a call from the RN noting there was an 18-year-old at Geisinger Medical Center (GMC) who the facility wanted to transfer to their hospital. OTH9 told the RN, they could not take the GMC 18-year-old transfer patient. OTH9 was adamant the receiving hospital did not accept the 18-year-old patient referred from Geisinger.

Review of receiving facility document "Fax Back Form" noted "It is the policy of the [hospital name] Behavioral Health Unit to ensure medical clearance of patients before admitting a patient to our unit. The following information is requested to be faxed to us at ..." a telephone number was provided, followed by a listing for the following: laboratory data/testing, commitment paperwork, documentation of medical clearance, as well as space for other documentation. This form also notes: "Please note that any documented overdose will require a 24 hour observation in an intensive care unit ICU or a medical-surgical care unit prior to admission to [hospital name] Behavioral Health Unit, to ensure the patient's medical stability."

Interview with OTH7 at approximately 3:15 PM revealed they worked January 18, 2015, 7-11 PM. OTH7 received an inquiry from GMC to send MR30. The inquiry was passed to the oncoming RN, as OTH7 was waiting for Geisinger to return the Fax Back Form for MR30. In the inquiry call, OTH7 was asked if beds were available. OTH7 said there were beds, but OTH7 would have to talk to the physician. OTH7 noted he spoke with the crisis worker only, OTH8. OTH11 received call back from OTH8, asking if we were taking MR30. OTH11 informed OTH8 the physician was not accepting the transfer. OTH7 stated the receiving hospital never received the Fax Back Form from Geisinger.