HospitalInspections.org

Based on observation, review of video recordings, interview, review of medical record documentation for 16 of 21 individuals who presented to the hospital for emergency services (Patients 1, 2, 3, 4, 6, 7, 8, 9, 10, 12, 13, 15, 16, 17, 18 and 19), review of the central log, review of internal investigation documentation and review of hospital policies and procedures it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures that ensured it met its EMTALA obligations in the following areas:
* To conspicuously post signs in all areas individuals wait for examination and treatment that specify individual's rights under EMTALA.
* To maintain a central log that was complete, and accurately reflected all individuals who presented for emergency services, the reasons they presented and their dispositions.
* To not dissuade individuals from staying to receive a MSE or otherwise delay examination and/or treatment in order to inquire about the individual's insurance or payment status.
* To provide MSEs for all individuals who present to the hospital for emergency services.
* To ensure the provision of MSEs by qualified practitioners.
* To obtain or attempt to obtain written and informed refusal of MSEs and treatment for individuals who refuse examination and treatment.
* To not delay an appropriate transfer to another hospital in order to inquire about insurance, for patients who require further examination and stabilizing treatment that is not within the hospital's capability and capacity.

Findings included:

1. Refer to the findings identified under Tag C2402, CFR 489.20(q) that reflects the hospital's failure to conspicuously post required EMTALA signs in all areas individuals wait for examination and treatment.

2. Refer to the findings identified under Tag C2405, CFR 489.20(r)(3) that reflects the hospital's failure to maintain a complete and accurate central log.

3. Refer to the findings identified under Tag C2406, CFR 489.24(a)&(c), that reflects the hospital's failure to ensure all individuals who presented for emergency services received a MSE and that MSEs were conducted by qualified practitioners.

4. Refer to the findings identified under Tag C2409, CFR 489.24(e) that reflects the hospital's failure to affect appropriate EMTALA transfers to other hospitals with the necessary capability and capacity for patients for whom an EMC had not been ruled out, removed or resolved.

Based on observation, interview and review of policies and procedures it was determined the hospital failed to develop and enforce EMTALA policies and procedures that ensured the posting of signage, that specified individuals' EMTALA rights with respect to examination and treatment for emergency medical conditions and women in labor, in all areas likely to be noticed and where individuals waited for examination and treatment.

Findings include:

1. The P&P titled "EMTALA and Transfer of Patients Responsibility during Transfer Medical Screening Exam (sic)" dated as last reviewed "11/08" reflected under "Posting of Signs" that "The hospital will conspicuously post the required signs in the Emergency Department and Obstetrical Department or in a place or places likely to be noticed by all individuals entering the Emergency Department."

2. During tour of the FBC on 11/19/2019 at 1535 the following observations were made:

There were two 8 1/2 inch by 11 inch signs, one in English and the other in Spanish, posted on blue paper on a wall to the left of the FBC nurse's station next to the "Emergency Exit Only" doors. At the time of the observation the corridor was dimly lighted and the verbiage on the signs was not readable except at a close distance.

There was no signage posted elsewhere outside or inside of the FBC where patients or their representatives, who waited for examination and treatment, would be likely to see their EMTALA rights, including in FBC waiting areas, at the locked FBC entrance, or inside the 12 LDRP rooms.

These findings were observed by the COO and FBCM at the time of the tour who confirmed there were no other EMTALA signs posted.

3. During tour of the ED on 11/19/2019 at 1530 the following observations were made:

There was a large EMTALA sign in English and one in Spanish posted in the ED ambulance entrance, and a large EMTALA sign in English and one in Spanish posted on a wall to the right of the ED registration desk. However, there was no signage posted elsewhere outside or inside of the ED where patients or their representatives, who waited for examination and treatment, would be likely to see their EMTALA rights, including in all areas of the ED lobby/waiting room, triage rooms and treatment rooms.

Those findings were observed by the VPN and the EDM during the tour who confirmed there were no other EMTALA signs posted.

Based on review of video recordings, interview, review of medical record documentation for 15 of 21 individuals who presented to the hospital for emergency services (Patients 1, 2, 3, 4, 6, 7, 9, 10, 12, 13, 15, 16, 17, 18 and 19), review of the central log, review of internal investigation documentation and review of hospital policies and procedures it was determined that the hospital failed to develop and enforce EMTALA policies and procedures that ensured a central log was maintained for completeness, and accurately reflected all individuals who presented for emergency services, the reasons they presented and their dispositions including whether they refused treatment or they were refused treatment:
* An individual who presented to the hospital for emergency services was directed by hospital registration staff to go to another hospital. The central log lacked an entry to reflect the individual had presented to the hospital.
* Incomplete and unclear central log entries included chief complaints and dispositions.

Findings include:

1. a. The P&P titled "EMTALA and Transfer of Patients Responsibility during Transfer Medical Screening Exam (sic)" dated as last reviewed "11/08" lacked reference to maintenance of a central log.

1. b. Review of the central log revealed that it did not contain the same information for all individuals who presented to the hospital for emergency services.

* For individuals who presented to the ED the log reflected:
- "ED Arrival Date/Time"
- "ED Departure Date/Time"
- "Chief Complaint"
- "ED Disposition"

* For individuals who presented to the FBC it was not clear who presented for emergency services and the log reflected:
- "ADT Events.Patient Class," identified as either "Observation," "Inpatient," or "Newborn."
- "Event Type," which was identified as "Admission" for every entry.
- "Effective DateTime"
- "Discharge Disposition"
- "Hospital Admission DateTime"
- "Hospital Discharge DateTime"

2. Review of the central log for 11/05/2019 reflected there was no entry to show that Patient 9 had presented to the hospital. Refer to the detailed findings described at Tag C2406 that reflects Patient 9 presented to the hospital and did not receive a MSE and was not entered into the central log.

3. The central log reflected that Patient 1 presented to FBC on 10/25/2019 at 0208 for "Observation." The reason the patient came to the hospital for emergency services was not specified.

4. The central log reflected that Patient 2 presented to the ED on 10/27/2019 at 1408. The "Chief Complaint" was not recorded and the space was blank.

5. The central log reflected that Patient 3 presented to the ED on 10/27/2019 at 1701. The "Chief Complaint" was recorded as "General Illness/General Recheck." However, the ED record reflected that the "arrival complaint" was recorded at 1702 as "Symptoms of Heart Attack."

6. The central log reflected that Patient 4 presented to FBC on 10/30/2019 at 1127 for "Observation." The reason the patient came to the hospital for emergency services was not specified.

7. The central log reflected that Patient 6 presented to the ED on 11/04/2019 at 1901. The "ED Disposition" was recorded as "Discharge" at 1951. However, the patient was not discharged to home or from the hospital. He/she was determined to be pregnant and was sent to the FBC for further examination and stabilizing treatment.

8. The central log reflected that Patient 7 presented to FBC on 11/04/2019 at 1959 for "Observation." The reason the patient came to the hospital for emergency services was not specified.

9. The central log reflected that Patient 10 presented to the ED on 11/06/2019 at 0326 with "Chief Complaint" of "Abdominal Pain." The log reflected the "ED Departure Time" was 1120 and the "ED Disposition" was recorded as "No disposition documented."

10. The central log reflected that Patient 12 presented to the ED on 11/10/2019 at 1343 with "Chief Complaint" of "Dysuria." The log reflected the "ED Departure Time" was 1617 and the "ED Disposition" was recorded as "No disposition documented."

11. The central log reflected that Patient 13 presented to the ED on 11/10/2019 at 2108. The "Chief Complaint" was not recorded and the space was blank.

The log also reflected that the patient "LWBS before Triage" and departed the ED at 2150. However, the ED record reflected that 2150 was the time the "Disposition selected." There was no documentation to reflect when the patient actually departed the ED.

12. The central log reflected that Patient 15 presented to the ED on 11/12/2019 at 0633. The "Chief Complaint" was not recorded and the space was blank.

13. The central log reflected that Patient 16 presented to the ED on 11/12/2019 at 1312. The "Chief Complaint" was not recorded and the space was blank.

The log also reflected that the patient "LWBS before Triage" and departed the ED at 1342. However, the ED record reflected that 1342 was the time the "Patient Dismissed." There was no documentation to reflect when the patient actually departed the ED.

14. The central log reflected that Patient 17 presented to the ED on 11/12/2019 at 2014 for "Rectal Bleeding" and "LWBS after Triage."

Although the log indicated the patient left after triage, the ED record reflected that triage had not been completed. The ED record reflected that triage had been started at 2027, a conversation with the patient occurred and the patient was "Dismissed" at 2032. The record lacked documentation to reflect that vital signs or other elements of triage had been conducted.

15. The central log reflected that Patient 18 presented to the ED on 11/13/2019 at 1234. The "Chief Complaint" was not recorded and the space was blank.

16. The central log reflected that Patient 19 presented to the ED on 11/13/2019 at 1534. The "Chief Complaint" was not recorded and the space was blank.

The log also reflected that the patient "LWBS before Triage" and departed the ED at 1605. However, the ED record reflected that 1604 was the time the "Disposition selected" and the "Patient discharged" at 1605. There was no documentation to reflect when the patient actually departed the ED.

17. The central log for the ED for 08/01/2019 to 11/19/2019 contained 31 entries for individuals who presented to the hospital for emergency services and the "ED Disposition" was recorded as "LWBS before Triage." For 27 of those entries the "Chief Complaint" of the individual was not recorded and those spaces were blank.

The central log for the ED for 08/01/2019 to 11/19/2019 contained 75 entries for individuals who presented to the hospital for emergency services and the "ED Disposition" was recorded as "LWBS after Triage." For three of those entries the "Chief Complaint" of the individual was not recorded and those spaces were blank.

Based on review of video recordings, interview, review of medical record documentation for 7 of 21 individuals who presented to the hospital for emergency services (Patients 4, 8, 9, 13, 16, 18 and 19), review of internal investigation documentation and review of policies and procedures it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures that ensured that every individual who presented to the hospital for emergency services received a MSE within the hospital's capability and capacity by qualified practitioners, and that hospital staff did nothing to dissuade patients from staying at the hospital for the provision of a MSE:
* An individual who presented to the hospital for emergency services did not receive a MSE and instead was directed by hospital registration staff to go to another hospital ED after insurance information was discussed. There was not another hospital in the same town.
* Other individuals who presented to the hospital for emergency services left the hospital before receiving a MSE for reasons that were unclear or unexplained or after insurance information had been obtained.
* An OB patient did not receive a MSE from a qualified practitioner. P&Ps did not clearly delineate between triage and MSE for OB patients but referenced the provision of MSEs by RNs. However, Medical Staff bylaws and rules and regulations did not allow for provision of MSEs by RNs and there was no evidence that RNs had special qualifications and competencies to perform MSEs in place of medical providers.

Findings include:

1. a. The P&P titled "EMTALA and Transfer of Patients Responsibility during Transfer Medical Screening Exam (sic)" dated as last reviewed "11/08" reflected "It is the policy of Good Shepherd Health Care System that physicians and hospital personnel comply with the applicable State and Federal requirements regarding patient transfers (421 CFR 489.24). A physician or approved Mid-Level provider shall perform a 'Medical Screening Exam' within the capabilities of the facility mandated by Federal law (42 CFR 489.24 (a)(i)) for any person that 'comes to the Emergency Department' ... In the event a physician is not available, properly trained ancillary personnel may perform the screening exam if approved by Medical Staff (such as in the OB area.)"

The P&P reflected "Medical Screening Examination: ... The MSE must be the same MSE that the hospital would perform for any individual coming to the Emergency Department with those signs and symptoms, regardless of the individual's ability to pay for medical care ... Must be completed by a physician or Mid level provider in the ER setting as defined in the hospital Bylaws and Rules and Regulations. May be completed by an RN in the OB setting as defined in the hospital Bylaws and Rules and Regulations."

The P&P did not specify what "approved Mid-Level provider" or "properly trained ancillary personnel" meant. Further, as reflected in the findings that follow in this deficiency, the medical staff Bylaws and Rules and Regulations did not specify what an OB MSE consisted of, nor include provisions for designation, credentialing, privileging or approval of FBC RNs to perform MSEs for OB patients.

1. b. The P&P titled "Providing medical care to patients/potential patients that come to the Good Shepherd Health Care System Campus" dated as last reviewed "7/11" reflected its purpose was "To meet State and Federal requirements (E.M.T.A.L.A.) concerning the identification and care of individuals on or near the hospital campus." The P&P reflected "When any individual that has come to the Emergency Department is requesting medical care for an emergency medical condition ... an EMTALA obligation on the part of the hospital may be triggered ..."

It was unclear what the P&P meant where it indicated the EMTALA obligation "may" be triggered.

1. c. The P&P titled "Obstetrical patients in the Emergency Room" dated as last reviewed "6/11" reflected "All OB patients will be screened and treated in accordance with the Federal [EMTALA] ... If the patient of 20 weeks gestation or greater presents to the hospital with an obstetrical problem ... she will be routed to the [FBC] of the hospital where she will be screened by the OB nurse and care will be assumed by her OB primary care provider or the OB physician on call ... Medical Screening of the OB Patient in the [FBC] and/or the [ED]. If the patient does not have an OB physician on staff, the OB physician on call will be notified to assume care. If this same patient does not meet criteria for admission, the OB physician on call will see the patient prior to discharge."

It was unclear what "screened by the OB nurse" meant, what "criteria for admission" was, and who was designated to determine if the criteria for admission was met.

1. d. The P&P titled "Obstetrical Outpatients/Observation Patients in FBC" dated as "formulated 11/02/2018" reflected "Keypoint: The steps in the obstetrical outpatient assessment and communication process constitute the elements of the Medical Screening Examination." It further reflected that "Assessment of the patient should occur in a timely manner following arrival and the assessment reported to the LIP. The minimal nursing assessment should include maternal vital signs, fetal heart rate, and uterine activity. The L.I.P. should be promptly notified when any of the following findings are present or suspected following the nursing assessment: ... Preterm labor ... Whenever a pregnant woman is evaluated for labor, the following factors should as assessed and documented ..."

The P&P reflected "If the patient is discharged home after being assessed as NOT in active labor, a physician, or a physician in telephone consultation with the nurse or nurse midwife, must certify that the patient is not in active labor. The L.I.P. order should read 'not in active labor, discharge home'."

It reflected "If the patient is assessed as being in labor and the LIP does NOT agree that it is reasonable for her to be discharged home, but the patient insists after being presented with the risks and benefits of discharge, the patient will be asked to sign the [AMA] form prior to her discharge ..."

It also reflected "Keypoint: The L.I.P. must be notified and orders obtained prior to discharge of the patient."

1. e. The "Bylaws of the Medical Staff of Good Shepherd Medical Center" dated as last reviewed on 06/09/2015 lacked designation, provisions and approval for FBC RNs to perform MSEs for pregnant patients who presented to the hospital.

1. f. The "Medical Staff Rules and Regulations of Good Shepherd Medical Center" dated as last revised on 02/18/2015 reflected that "In accordance with State and Federal regulations, it is the rule of Good Shepherd Medical Center to provide physician on-call coverage to best meet the needs of patients presenting with emergency medical conditions."

In regards to "Obstetrical Care" the rules and regulations lacked designation of who was authorized by the medical staff to conduct MSEs for pregnant patients who presented to the hospital.

1. g. The "Credentialing Manual of the Medical Staff of Good Shepherd Medical Center" dated as last revised 09/17/2013 reflected that "Other practitioners: (specifically, Clinical Psychologist ... Registered Nurse Anesthetist, Podiatrist, Registered Physician Assistant, Certified Nurse Practitioner) will be permitted to apply for specific clinical privileges."

The credentialing manual lacked designation, provisions and approval for FBC RNs to perform MSEs for pregnant patients who presented to the hospital.

1. h. The "Policy on Allied Health Professionals Manual of the Medical Staff of Good Shepherd Medical Center" dated as last reviewed on 07/12/2013 reflected that "All allied health professionals who are permitted to practice at the Medical Center shall be classified in one of two categories: Non-sponsored Allied Health Professionals or Sponsored Allied Health Professionals." Appendix A reflected that "Non-sponsored Allied Health Professionals at [GSMC] are as follows: Clinical Psychologists ... Certified Registered Nurse Anesthetists ... Podiatrists." Appendix B reflected that "Sponsored Allied Health Professionals at [GSMC] are as follows: Registered Physician Assistants ... Advanced Registered Nurse Practitioners ... Registered Nurse First Assistants ... Certified Dental Assistants."

The policy manual lacked designation, provisions and approval for FBC RNs to perform MSEs for pregnant patients who presented to the hospital.

1. i. The P&P titled "Emergency Room Admitting and Payment Policy" dated as reviewed "9/11" reflected its purpose was "To maintain compliance with EMTALA ... while effectively collecting payments for services rendered in the Good Shepherd Emergency Department." The P&P reflected "All patients presenting to the Emergency Department requesting treatment will be given an appropriate medical screening exam in accordance with Hospital policy and state and federal law. All patients will be seen and evaluated regardless of their financial situation. Subsequent to evaluation co-pays, co-insurances and deductibles will be requested from all stabilized or non-emergency patients for services rendered. Uninsured patients will be evaluated for payment or financial assistance ... Upon stabilization, the Patient Financial Services Department will be notified to complete the admitting process. Upon discharge, the patient will be escorted to Financial Counseling for payment arrangements and financial screening."

1. j. The P&P titled "Patient Financial Assistance" dated as reviewed "9/11/" reflected "GSHCS will provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the FAP. It will meet the requirements of existing federal laws such as [EMTALA]. It will not discourage individuals from seeking appropriate emergency medical care."

1. k. The ED P&P titled "Refusal of MSE/LWBS/AMA" dated as reviewed "6/11" reflected it's purpose was "To provide appropriate documentation when a patient leaves [AMA] or refuses a procedure by a physician/provider." The P&P required the following:
* "The physician/provider is to be contacted. If, in the opinion of the physician/provider responsible for the patient's care, leaving the facility will be detrimental to the patient's health, every effort should be made to educate the patient regarding the consequences of leaving."
* "If the patient elects to leave regardless of the medical advice provided, the AMA form shall be completed by the physician/provider/nurse and will become part of the patient's medical records."
* "If the patient chooses to leave without being seen, the staff, to the best of their ability will document in the patient's medical record, the reason the patient has decided to leave and the discussion on the risks of leaving."
* "If the patient leaves without the staffs (sic) awareness, this will be documented in the medical record as thoroughly as possible."
* "The physician/provider shall record in the medical record that the patient was discharged against medical advice and medical consequences of the patient's decision were explained in detail. These medical consequences should be listed by the physician/provider in the discharge note."

2. a. During interview with the QM on 11/19/2019 at 1515 he/she confirmed that it had been reported to the hospital that Patient 9 had presented to the ED registration desk for emergency services, had presented a CA Medicaid card, was told that GSMC would not accept CA Medicaid and left GSMC without an MSE. The QM stated that the hospital had initiated an investigation of the incident. He/she acknowledged that there was a lack of EMTALA training for registration staff and they were working on improving that and developing "scripting" for staff.

2. b. Incident and investigation documentation related to Patient 9 was reviewed and included the following:
* Notes dated 11/06/2019 reflected "Unable to locate [Patient 9] in Epic."
* Notes dated 11/06/2019 reflected that Patient 9 "... arrived to Kadlec ED at 17:22 on 11/05/2019 ... needed a translator."
* Notes dated 11/12/2019 reflected the patient "... had first gone to Good Shepherd because [he/she] has a history of cardiac issues (visiting from California). Was directed by California doctor to go to nearest hospital. When they got in, the police were there and talking to a man and woman ... [adult child] very fluent in english. (sic) Had [his/her] insurance card out and was holding it - reportedly, the [PFS employee] said 'just so you know, we don't take your insurance' - was told they would have to pay 20% of the visit before being seen. [Adult child] asked if they were going to take vital signs or begin care, were told they need to go to Kadlec or another ED. So they left."
* Notes dated 11/12/2019 reflected that Patient 9 presented to Kadlec and at that time he/she was "Bradycardic, HR of 30. New onset of 3rd degree block. Admitted."
* Notes dated 11/20/2019 reflected "Currently, no formal training specifically to EMTALA is being provided to PFS staff."

2. c. Video recording, without audio, of the ED registration desk was reviewed with the VPN, QM and FBCM on 11/19/2019 beginning at 1500. The video showed the following on 11/05/2019:
* At 1557 a hospital security officer pushed Patient 9 in a wheelchair from outside, through the main ED entrance and to the ED registration desk.
* Patient 9 was observed to be of senior age and was accompanied by four other younger adult and child individuals.
* A PFS employee from the other side of the registration desk was observed to interact with members of the group.
* At 1600 the group who accompanied the patient turned away from the registration desk and pushed Patient 9 in the wheelchair out of the hospital.
* The PFS employee and other staff present in the area at that time did not approach the patient as he/she was being pushed out of the hospital.

2. d. Review of an internal email dated 11/12/2019 at 1424 reflected that video had been reviewed and included the following:
"This may have been the [individual] in question ... based on:
* Hispanic description
* Possible patient in a wheelchair with family attending
* They arrived, talked at the window and then left. They were not triaged or seen.
* There are policemen in the waiting room, which fits the ... description
* The time of in the lobby (15:58 - 16:00) fits well with the time they arrived at Kadlec (17:22).
... the [individual] in the wheelchair is older ..."

2. e. Review of an internal email dated 11/12/2019 at 1609 reflected that the PFS employee "recalls having patient present to the Window and provide [him/her] with MCR and CA Medicaid Insurance cards. [PFS employee] provided CA Medicaid insurance card back to patient, due to being out of state. Patient asked why are giving me back the card. [PFS employee] stated, we are not contracted with out of state Medicaid, but no worries we are going to get you see (sic) today, and I will scan your MCR card. Patient then decide (sic) to leave and stated if [PFS employee] knew another hospital that accepted CA Medicaid, [PFS employee] stated we do not, but we can still see you, we will have someone come talk to you in the back, because we have programs to assist you. Patient was apprehensive about being seen and stated their doctor in California told them CA Medicaid would cover over here. [PFS employee] continue (sic) to encourage the patient to get seen and to allow us to talk to them about any balance in the ER room. Patient still decided to leave. [PFS employee] assured them MCR would cover 80% to not worry. Patient did not care. Potentially this is where 20% might of (sic) come from."

2. f. Review of the central log for 11/05/2019 reflected there was no entry to show that Patient 9 had presented to the hospital.

2. g. An Internet distance calculator reflected that Kadlec Hospital in Kennewick, WA is approximately 50 miles and one hour drive-time from GSMC.

3. a. The central log reflected that Patient 4 presented to FBC on 10/30/2019 at 1127 for "Observation." The reason the patient came to the hospital was not specified.

3. b. The FBC record for Patient 4 was reviewed and reflected a timeline that included the following
* At 1145 an RN recorded the patient's vital signs recorded "Chief Complaints" as "Decreased Fetal Movement (Since last night)."
* Between 1145 and 1150 the RN recorded nursing assessment information.
* At 1230 "Fetal Heart Rate" and "Uterine Activity" were recorded.
* At 1233 physician orders for "Fetal Monitoring" were "placed" or initiated, after the monitoring had occurred.
* At 1236 an RN recorded "OB Provider Notification" under a "Labor" heading.
* At 1237 physician orders to "Discharge Patient" were "placed."
* At 1239 an RN recorded "Patient discharged."
* Final Diagnosis information recorded on the patient demographics form reflected "Decreased fetal movements, third trimester, no applicable or unspecified."

There were no narrative or other notes in the record by the physician to reflect that an MSE had been conducted, what medical decision-making had occurred and whether the physician determined that the patient did not have an EMC.

There were no narrative or other notes in the record by the RN to reflect how communication with the physician had occurred and what his/her communication with the physician had been.

3.c. During interview with the VPN and FBCM on 11/20/2019 at 1430 they stated that the medical staff bylaws and hospital P&Ps do not include designation of who may conduct MSEs for OB patients. They stated that although it is their "practice" that the FBC RNs who have completed L&D orientation, FM training and demonstrate initial and annual competency may perform MSEs, that is not evident in bylaws or P&Ps.

In addition, the VPN and FBCM confirmed the findings for Patient 4 at the time of the record review at 1500.

4. a. The central log reflected that Patient 8 presented to the ED on 11/05/2019 at 0827 for "Emesis" and "LWBS after Triage." The "ED Departure Time" was recorded as 0855.

4. b. The ED record for Patient 8, a seven-year-old, was reviewed and reflected the following timeline:
* At 0827 "ED Arrival Information" reflected the seven-year-old was "Escorted By Self."
* At 0832 an RN recorded the word "Patient" under "ED Notes."
* At 0835 an RN recorded "Triage Start."
* At 0836 the RN recorded partial vital signs of a temperature of 99.5, a HR of 106, Respirations of 22 and O2 sat of 95% and "Patient arrives to ed with complaint of vomiting since Sunday, not keeping anything down."
* At 0837 the RN recorded "Triage Completed."
* At 0842 the RN recorded the administration of an oral medication "given while patient in lobby."
* At 0843 the RN recorded "Patient roomed in ED To room ST."
* At 0855 the RN recorded "Patient discharged."

There was no other documentation in the record, including an AMA form, to reflect who brought the seven-year-old patient to the hospital and why the patient who had abnormal vital signs was "discharged" prior to an MSE.

4. c. "Account History" documentation associated with the ED record was reviewed and reflected the following on 11/05/2019:
* At 0827 "Changed Account Base Class, Account Class, Billing Status, and 3 more."
* At 0842 "Changed Hospital Account Coverage List ... Old Value [blank] ... New Value MODA ODS MNGD MCAID ..."

The record reflected that information that the patient's insurance was Medicaid was obtained prior to the MSE and there was no documentation to reflect how that information was provided and what communication occurred.

4. d. During interview with the EDM at the time of the record review on 11/20/2019 at 1158 he/she stated in regards to "Patient roomed in ED To room ST," that "ST" was a "workaround" to allow physician orders to be generated in the EPIC EHR system when the patient was in the lobby and not in an actual ED treatment room. The EDM further confirmed there were no other notes by ED or PFS staff.

5. a. The central log reflected that Patient 13 presented to the ED on 11/10/2019 at 2108. The "Chief Complaint" was not recorded and was blank. The log also reflected that the patient "LWBS before Triage" and departed the ED at 2150.

5. b. The ED record for Patient 13, a six-month-old, was reviewed and reflected the following timeline:
* At 2108 "ED Arrival Information" reflected the six-month-old was "Escorted By Self."
* At 2108 "Arrival Complaint" was recorded as "fell on head."
* At 2136, the next entry, reflected "Registration Completed."
* At 2150, the next entry, an RN recorded "Patient dismissed" and "ED Disposition set to LWBS before Triage."

There was no other documentation in the record, including an AMA form, to reflect who brought the six-month-old patient into the hospital and why the patient was "dismissed" and left prior to an MSE.

5. c. "Account History" documentation associated with the ED record was reviewed and reflected the following on 11/10/2019:
* At 2108 "Changed Account Base Class, Account Class, Billing Status, and 4 more ... Hospital Account Coverage List - Old Value [blank] - New Value MODA ODS MNGD MCAID ..."

The record reflected that information that the patient's insurance was Medicaid was obtained prior to the MSE and there was no documentation to reflect how that information was provided and what communication occurred.

5. d. During interview with the EDM at the time of the record review on 11/20/2019 at 1135 he/she stated that registration is supposed to be at the "bedside" after the MSE, and he/she didn't know why registration was completed prior to triage and the MSE.

6. a. The central log reflected that Patient 16 presented to the ED on 11/12/2019 at 1312. The "Chief Complaint" was not recorded and was blank. The log also reflected that the patient "LWBS before Triage" and departed the ED at 1342.

6. b. The ED record for Patient 16 was reviewed and reflected the following timeline:
* At 1313 "Arrival Complaint" was recorded as "Neck Pain MVA 11/11/19."
* At 1342, the next entry, an RN recorded "Patient dismissed."

There was no other documentation in the record, including an AMA form, to reflect why the patient was "dismissed" prior to an MSE.

6. c. "Account History" documentation associated with the ED record was reviewed and reflected the following on 11/12/2019:
* At 1323 "Changed Account Base Class, Account Class, Billing Status, and 4 more ... Hospital Account Coverage List - Old Value [blank] - New Value MODA ODS MNGD MCAID ..."
* At 1346 "[Name] viewed the following ... Acct Summary - Coverages - Hosp Acct Note."
* At 1346 "Pt Left Without Being Triaged."

The record reflected that information that the patient's insurance was Medicaid was obtained prior to the MSE and there was no documentation to reflect how that information was provided and what communication occurred.

7. a. The central log reflected that Patient 18 presented to the ED on 11/13/2019 at 1234. The "Chief Complaint" was not recorded and was blank. The log also reflected that the patient "LWBS before Triage" and departed the ED at 1249.

7. b. The ED record for Patient 18, a 17-year-old, was reviewed and reflected the following timeline:
* At 1234 "ED Arrival information" reflected that patient was "Escorted by Other (Doctor)."
* At 1234 "Arrival Complaint" was recorded as "Crohns Disease Poss Abd Abscess."
* At 1238 an RN recorded "Patient roomed in ED To room 04."
* At 1242 an RN recorded "Pt in restroom."
* At 1246 the RN recorded "Pt walked out of ambulance bay."
* At 1249 the RN recorded "Patient discharged."
* At 1249 "Registration Completed" was recorded.

There was no other documentation in the record, including an AMA form, to explain who "Other (Doctor)" was that brought the patient to the hospital. There was no documentation to reflect why the patient walked out of the hospital prior to an MSE nor that staff made any attempt to stop the patient from leaving to have an AMA discussion.

7. c. "Account History" documentation associated with the ED record was reviewed and reflected the following on 11/13/2019:
* At 1234 "Changed Account Base Class, Account Class, Billing Status, and 4 more ... Hospital Account Coverage List - Old Value [blank] - New Value United Healthcare ... Blue Cross ..."
* At 1240 "[Name] viewed the following ... Acct Summary - Hosp Acct Note."
* At 1240 "Pt brought straight to the back by Dr. Checked into ER. Band placed on pts L wrist."
* At 1241 "[Name] viewed the following ... Acct Summary - Hosp Acct Note."
* At 1242 "[Name] viewed the following ... Acct Summary."
* At 1242 "... Ins Effective on DOS."

The record reflected that the patient's insurance information was obtained prior to the MSE and there was no documentation to reflect how that information was provided and what communication occurred.

8. a. The central log reflected that Patient 19 presented to the ED on 11/13/2019 at 1534. The "Chief Complaint" was not recorded and was blank. The log also reflected that the patient "LWBS before Triage" and departed the ED at 1605.

8. b. The ED record for Patient 19, a 15-month-old, was reviewed and reflected the following timeline:
* At 1534 "ED Arrival Information" reflected the 15-month-old was "Escorted by Self."
* At 1535 "Arrival Complaint" was recorded as "Difficulty Breathing."
* At 1604, the next entry, an RN recorded "Patient roomed in ED To room OTF."
* At 1604, the RN also recorded "ED Disposition set to LWBS before Triage."
* At 1605, the RN recorded "Patient discharged."

There was no other documentation in the record, including an AMA form, to reflect who brought the 15-month-old patient into the hospital and why the patient left immediately after being "roomed in ED" prior to an MSE.

8. c. "Account History" documentation associated with the ED record was reviewed and reflected the following on 11/13/2019:
* At 1534 "Changed Account Base Class, Account Class, Billing Status, and 4 more ... Hospital Account Coverage List - Old Value [blank] - New Value MODA ODS MNGD MCAID ..."

The record reflected that information that the patient's insurance was Medicaid was obtained prior to the MSE and there was no documentation to reflect how that information was provided and what communication occurred.

8. d. During interview with the EDM at the time of the record review on 11/20/2019 at 1020 he/she confirmed that there were no notes, no flowsheets, no description of the encounter including who brought the child to the hospital and no explanation for lack of a MSE for a 15-month-old with difficulty breathing.

Based on interview, review of documentation in 1 of 3 ED medical records of patients who were transferred from GSMC to another hospital for specialty services not available at GSMC (Patient 3) and review of hospital policies and procedures, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure that it did not delay an appropriate transfer for a patient who required further examination and stabilizing treatment for an EMC that had not been removed or resolved.
* After a receiving hospital had accepted the patient for cardiology services, the transfer was delayed until insurance had authorized payment for transportation.

Findings include:

1. The P&P titled "Emergency Room Admitting and Payment Policy" dated as reviewed "9/11" reflected its purpose was "To maintain compliance with EMTALA ... while effectively collecting payments for services rendered in the Good Shepherd Emergency Department." The P&P reflected "All patients presenting to the Emergency Department requesting treatment will be given an appropriate medical screening exam in accordance with Hospital policy and state and federal law ... Upon stabilization, the Patient Financial Services Department will be notified to complete the admitting process. Upon discharge, the patient will be escorted to Financial Counseling for payment arrangements and financial screening. Patients who are admitted or require transfer to another facility will be exempt from this policy."

2. a. The central log reflected that Patient 3 presented to the ED on 10/27/2019 at 1701. The "Chief Complaint" was recorded as "General Illness/General Recheck."

2. b. The ED record for Patient 3 was reviewed and reflected a timeline that included the following:
* At 1702 the "arrival complaint" was recorded as "Symptoms of Heart Attack."
* At 1705 "Chief Complaints" recorded included "Chest Pain" and the ED physician placed orders for an EKG.
* Between 1705 and 1734 the record reflected an extensive MSE was performed and stabilizing treatment provided.
* At 1734 an entry reflected that "Registration Completed."
* Between 1734 and 1935 the MSE and stabilizing treatment continued and included hospitalist and cardiologist consults.
* At 1935 the patient was accepted by Trios Hospital as a transfer for cardiology services.
* At 2005 a note recorded on the ED Provider Notes reflected "Action plan (To Do): Pt accepted for transfer, awaiting for insurance to approve transport."
* At 2021 an ambulance transport was requested, 46 minutes after the transfer was accepted by the receiving hospital.
* At 2027 the ambulance company reported an ETA to hospital of 30 minutes.
* At 2100 the ambulance arrived, one hour and 25 minutes after the transfer was accepted by the receiving hospital.
* At 2114 the patient departed the hospital for ambulance transport to Trios Hospital for cardiology services with a diagnoses of "Elevated troponin" and "TIA, NSTEMI."

2. c. These findings were confirmed with the EDM, HIMM and QRN at the time of the record review on 11/20/2019 at 1350.

2. d. An Internet distance calculator reflected that Trios Hospital in Richland, WA is approximately 28 miles and 38 minutes drive-time from GSMC.