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Based on observation, document review, and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to provide a medical screening exam, including reassessment of the patient while waiting for medical screening by a qualified practitioner, to determine if an emergency medical condition existed. See deficiency A-2406.

2. The Hospital failed to ensure an appropriate transfer to another medical facility by completing a physician certification regarding the medical benefits and risks of transfer; ensuring the receiving hospital agree to accept the transfer; and/or that the medical records related to the emergency condition, which the patients presented, were available and sent at the time of transfer. See deficiencies A-2409 A, B, and C.

Based on document review, observation and interview, it was determined that the Hospital failed to post signage regarding the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor (EMTALA), in a place or places likely to be noticed by all individuals entering the emergency department, as required.

Findings include:

1. The Hospital's policy titled, "Emergency Medical Treatment and Transfer" (revised July 2021), was reviewed on 11/7/2022 and required, "The hospital shall post signs in conspicuous locations in the Emergency Department, or other location in the Hospital where emergency services are provided, specifying the rights of individuals under EMTALA with respect to examination and treatment for Emergency Medical Conditions. These signs shall specify that the Hospital participates in the Medicare and Medicaid program and will be posted in English and other major languages that are common to the population of the area served."

2. On 11/7/2022 between 9:40 AM through 10:40 AM, and on 11/9/2022 at approximately 9:00 AM, observational tours of the ED were conducted. The entrance and registration areas for patients brought in by ambulances did not have signage regarding the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor.

3. On 11/7/2022 at approximately 9:45 AM and on 11/9/2022 at approximately 9:00 AM, interviews were conducted with E #5 (ED Manager) and MD #3 (ED Medical Director). E #5 stated that signage is posted in the waiting area for patients who walk into the Hospital's ED. E #5 clarified that the signage for walk-in patients could not be seen by all patients, especially those brought in by ambulances. MD #3 said that signage should be posted and visible to all patients entering the Hospital's ED.

Based on document review and interview, it was determined that for 1 of 4 clinical records (Pt. #18) reviewed for patients identified as leaving the Emergency Department (ED) without being seen, the Hospital failed to provide a medical screening exam, including reassessment of the patient while waiting for medical screening by a qualified practitioner, to determine if an emergency medical condition existed.

Findings include:

1. On 11/9/2022, the Hospital's policy titled, "Emergency Medical Treatment and Transfer (EMTALA)" (reviewed by the Hospital on 7/2021) was reviewed and included, "... IV... ii. Medical Screening. All individuals who come for emergency services shall receive an appropriate medical screening examination. A physician must perform the medical screening exam to determine, with a reasonable confidence, whether an Emergency Medical Condition exists..."

2. On 11/9/2022, the Hospital's policy titled, "Emergency Department Triage Policy" (revised on 7/2021) was reviewed and included, "... Triage Categories... c. Level 3 Urgent... Special Considerations... Patients awaiting definite care will be reassessed hourly to assure that any change in patient condition will be detected and the plan for care and the urgency modified accordingly..."

3. On 11/9/2022, the Hospital's policy titled, "Assessment/Reassessment of Patient in the Emergency Department Protocol" (reviewed by the Hospital on 7/2021) was reviewed and included, " ... Definitions - Assessment is an ongoing process that begins when the patient arrives in the ED and continuous through treatment ... Reassessment intervals: Vital signs should be done ... 3. After interventions or treatments ..."

4. On 11/9/2022, the clinical record of Pt. #18 was reviewed. Pt. #18 was brought to the Hospital's ED by emergency medical services on 11/1/2022 due to chest pain, shortness of breath, cough, and fever for two days. The clinical record included:

- At 7:52 PM, Pt. #18 was triaged with an emergency severity index of 3 (urgent). Pt. #18's vital signs were as follows: BP (blood pressure) 108/56, pulse 117 (abnormal, normal is 60 to 100), respiration: 16 (normal), and temperature 101.1 (abnormal, normal is 97 to 99 degrees Fahrenheit). Pt. #18 had a pain score of 8 (severe pain).

- At 7:56 PM, Pt. #18 was given Tylenol (medication for pain and fever).

- At 8:00 PM, a nasal specimen was collected from Pt. #18 to check for the presence of influenza (flu).

- At 11:17 PM, the clinical record indicated, "... (Pt. #18) not in waiting areas and not in restroom. (Pt. #18 left the ED without being seen) ..."

- From 8:00 PM through 11:00 PM, Pt. #18's clinical record lacked documentation of a reassessment or medical screening exam (approximately three hours).

5. On 11/9/2022 at approximately 11:45 AM, findings were discussed with E #5 (ED Manager) and MD #3 (ED Medical Director). E #5 stated that nurses are expected to monitor and evaluate the patient's condition as required by the Hospital's protocol. MD #3 stated that the nursing assessment is ongoing and part of the medical screening examination. MD #3 said that a medical screening was not completed for Pt. #18.

A. Based on document review and interview, it was determined that for 1 of 10 clinical record (Pt. #1) reviewed for transfer to another facility, the Hospital failed to ensure that the receiving facility had agreed to accept transfer of the individual and to provide appropriate treatment.

Findings include:

1. The Hospital's policy titled, "Emergency Medical Treatment and Transfer" (revised July 2021), was reviewed on 11/7/2022 and required, "Process for the Appropriate Transfer of the Unstable Patient: ...iii. The RN or the Emergency Department physician/ED resident, attending physician, house physician, labor and delivery physician, or nurse midwife, shall call the receiving hospital and obtain approval for transfer and shall document the approval ..."

2. The clinical record of Pt. #1 at Hospital A was reviewed on 11/7/2022. Pt. #1 presented to Hospital A's emergency department (ED) on 9/12/2022, at 7:08 PM by ambulance with a chief complaint of alcohol withdrawal.

- The Emergency Department Physician Note on 9/12/2022, at 7:34 PM, included, "[Pt. #1] with past medical history significant for chronic alcohol abuse with prior DTs [delirium tremens] and withdrawal seizures... who presents to the emergency department with complaint of withdrawals and requesting detox ... States last drink was 24 hours ago. Normally drinks 1 pint of vodka daily. Currently feels 'shakey' and nauseous and states vomiting NBNB [non-bloody, non-bilious] emesis x1... Also complaining of epigastric abdominal pain. Assessment & Plan: Diagnosis: 1. Alcohol abuse. 2. Non-intractable vomiting with nausea... MDM [Medical Decision Making]: ...as noted above presenting for request for alcohol detox and concern for withdrawal. Currently slightly tachycardic, non-tremulous nor diaphoretic therefore possibly very mild withdrawals at this time. Will plan to treat symptomatically as well as discuss with SW [social worker] for detox resources. Additionally w/ N/V [nausea/vomiting] there is concern for possible EtOH [alcohol] gastritis vs [versus] pancreatitis as well as susceptible to electrolyte derangements from GI [gastrointestinal] losses and poor nutrition ... Dispo: PENDING reassessment and labs. Signed out to oncoming ED team ..."

- A Crisis Worker (E#2) Note, dated 9/12/2022 at 10:31 PM, included, "CW [crisis worker] spoke with pt who voluntarily seeking medical detox. Pt can be transported via Medicare ride to [Hospital B] ED for detox intake ..."

- A Nursing Note by ED Registered Nurse/RN (E#4) on 9/12/2022 at 10:43 PM included, "Spoke to [E#2] (Crisis Worker), pt will have a direct transfer to [Hospital B] ED Intake. Pt is to show up, Hospital is expecting him."

- An ED Provider Note by MD#2, dated 9/12/2022 at 10:44 PM, included, "Patient endorsed to me at change of shift. Patient has been accepted for transfer to [Hospital B] for detox. RN to call ambulance for transportation."

- The ED Timeline indicated that on 9/12/2022 at 10:46 PM, MD#2 set Pt. #1's disposition to "Transfer for Another Facility" and included a comment, "[Pt. #1] should be transferred out to [Hospital B]." Pt. #1 was transferred by ambulance to Hospital B on 9/13/2022, at approximately 5:00 AM.

- An ED Attending Attestation Note (by MD#1), signed 9/14/2022 at 5:24 PM, included: "A/P [Assessment & Plan]: -Pt in withdrawal, requesting detox placement. Will check electrolytes, BNP [brain natriuretic peptide], INR [international normalized ratio] for liver dysfunction, and etoh level, to evaluate for possible medical clearance. Will treat symptomatically for withdrawals, N/V, and dehydration. Labs pending, crisis eval pending, signed out to oncoming MD."

- The record did not include any other provider documentation to indicate that Pt. #1 was reassessed by a physician or other qualified medical provider and that Pt. #1's emergency medical condition was stabilized for discharge and/or transfer. The clinical record lacked documentation of any completed transfer forms and lacked documentation of nurse-to-nurse and/or physician-to-physician communication made with the receiving hospital (Hospital B) to accept Pt. #1's transfer.

3. The clinical record of Pt. #1, from Hospital B, was reviewed on 11/9/2022. Pt. #1 presented to Hospital B's ED on 9/13/2022, at approximately 5:29 AM by ambulance.

- The record received by Hospital B from Hospital A included Pt. #1's ED record; however, the section titled, "RN Documentation To be Completed At Transferring Hospital By Nursing/Crisis Worker - Select Site of Transferring Facility" was left blank and lacked information regarding contact with the receiving hospital such as the transferring physician's name, receiving physician's name, and whether the transfer was accepted.

- The ED History and Physical/Evaluation, dated 9/13/2022 at 5:49 AM, included, "[Pt. #1] who sent by ambulance from [Hospital A] for alcohol detoxification and withdrawal. Notes from the other hospital indicate that the crisis worker here [accepted] the patient. Crisis worker states he told him on the phone that we do not expect [accept?] direct admissions for detox. I was not aware of the patient prior to the patient arriving... Medical Decision Making and ED Course Differential diagnoses considered during course of visit include but are not limited to: Alcohol withdrawal, risk of seizure, risk of electrolyte disorder, hypomagnesemia, alcohol use disorder, alcohol intoxication, risk of respiratory depression with benzodiazepines. Initial interventions: Patient's CIWA-AR is 11 arrival here. We will give further benzodiazepines and monitor carefully. At 5:56 AM, I discussed with hospitalist ... patient had recent labs at another institution. Labs pending here. He will hospitalize on telemetry as patient will require prolonged stay given the possibility of a recent seizure and moderate alcohol withdrawal despite receiving Valium ... MDM discussion: Patient sent from another hospital. They apparently thought this is going to be transferred although transfer was not discussed with me nor excepted by this hospital. Patient has alcohol withdrawal. Long history of similar. Ongoing withdrawal symptoms. Will require hospitalization..."

- Pt. #1 was admitted to Hospital B's Telemetry/Medical Unit on 9/13/2022, with diagnoses of alcohol withdrawal syndrome with complication; alcohol use disorder, severe dependence; and hypomagnesemia.

4. A telephone interview was conducted with the Crisis Worker (E#2) and the Senior Clinical Director of Emergency Services for E#2's Contracted Social Services Company (E#3) on 11/7/2022, at approximately 2:15 PM. E#2 stated that Pt. #1 came in for alcohol detox. MD#1 reported that Pt. #1 had requested admission to an alcohol detox program. E#2 stated that MD#1 had made a request to see if another detox program was available in order to avoid an overnight stay, as it was a busy night. E#2 then contacted Hospital B's intake department and was told that they had a bed available in their program, but Pt. #1 would need to arrange his own transport to Hospital B. E#2 stated that Pt. #1's insurance covered Medicar transport, so they arranged the transportation for Pt. #1. E#2 stated that MD#1 was not planning to discharge Pt. #1 as Pt. #1 wanted to go to some type of detox program. E#2 and E#3 both stated that they received EMTALA training and know that they do not send patients from ED to ED. E#3 stated that E#2 intended for Pt. #1 to go to intake, not for an ED to ED transfer; however, E#2 was aware that Pt. #1 would have to be evaluated at Hospital B's ED as part of Hospital B's detox intake process.

5. A telephone interview was conducted with the ED Attending Physician (MD#1) on 11/7/2022, at approximately 3:00 PM. MD#1 stated that Pt. #1 presented with mild alcohol withdrawal symptoms and requested to go to an alcohol detox program. MD#1 stated that the Crisis Worker team found a place for Pt. #1. MD#1 stated that typically when a patient presents with alcohol withdrawal symptoms, they are watched in the ED for a while to make sure they don't have any severe/deadly withdrawal symptoms. MD#1 stated that she conducted the initial medical screening and was still awaiting some laboratory results when she completed her assessment and planning for Pt. #1. MD#1 stated that she gave report to the oncoming physician at the end of her shift (approximately 11:00 PM) and did not medically clear Pt. #1 at the time when MD#1 signed off. MD#1 stated that ideally, physicians will document an updated note to indicate that the patient has been medically cleared.

6. A telephone interview was conducted with the ED Discharging Physician (MD#2) on 11/7/2022, at approximately 2:40 PM. MD#2 stated that MD#2 did not have much interaction or participation with Pt. #1. MD#2 stated that it was reported that Pt. #1 was going to go to the Detox Unit at Hospital B and that all the arrangements had been made. MD#2 did not communicate with Hospital B staff and stated that it's the nurse who documents the necessary information for transfers. MD#2 believed that Pt. #1 was supposed to be a direct admission into Hospital B's voluntary detox inpatient program and was told that Pt. #1 had been accepted. MD#2 stated that the nurse and crisis team arranged to have the patient transported there and Pt. #1 was sent by ambulance. MD#2 stated that Pt. #1 was medically cleared; however, did not recall if MD#2 documented a final assessment. MD#2 stated, "Typically, yes we do put a statement in the record that they are medically cleared for detox."

7. A telephone interview was conducted with ED Nurse (E#4) on 11/9/2022, at approximately 12:50 PM. E#4 stated that she mainly interacted with MD#1 regarding Pt. #1's ED course. E#4 believed Pt. #1 was set to be discharged and that they were just helping to arrange transportation to Hospital B as a courtesy. E#4 stated that she asked the Crisis Worker (E#2) twice if she needed to complete the nurse-to-nurse report with Hospital B for Pt. #1. E#4 stated that E#2 told her that this was a discharge and that the nurse-to-nurse report was not necessary. E#4 stated that in cases when the patient is being transferred to another hospital, there are sections in the electronic medical record that the nurse needs to fill out. E#4 stated that a nurse report is always completed and it will be documented in this section, as well as the admitting physician's name.

8. An interview with the ED Medical Director/Chief Medical Officer (MD#3) was conducted on 11/9/2022, at approximately 9:08 AM. MD#3 stated that he got involved in the investigation after hearing from Hospital B. MD#3 stated that after talking with the physicians, there was some miscommunication that occurred which led to the patient being dispositioned as "transfer to another hospital" instead of being medically cleared and discharged first, as they typically do. MD#3 stated that if a patient is being sent from the ED to another ED, there definitely needs to be physician-to-physician communication. MD#3 stated that MD#2 thought Pt. #1 was going to one of the usual detox programs, not to another hospital's ED. MD#3 stated that this should've been caught at sign out and that the process needs to be tightened up.



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B. Based on document review and interview, it was determined that for 1 of 10 patients (Pt. #7) clinical records reviewed for transfers, the Hospital failed to complete a physician certification regarding the medical benefits and risks of transfer.

Findings include:

1. On 11/9/2022, the Hospital's policy titled, "Emergency Medical Treatment and Transfer (EMTALA)" (reviewed by the Hospital on 7/2021) was reviewed and included, "... F. Process for the Appropriate Transfer of the Unstable Patient...ii...The Emergency Department physician... determines... the medical benefits which are reasonably expected from appropriate medical treatment at another facility, outweighs the risks to the individual associated with the transfer... This determination and the risks and benefits... shall be documented and signed by the certifying physician..."

2. On 11/9/2022, the clinical record of Pt. #7 was reviewed. Pt. #7 was brought to the emergency department (ED) on 9/11/2022 due to drug ingestion and depression. The clinical record indicated that there was a safety concern regarding Pt. #7 intentionally ingesting 30 tablets of Zoloft/antidepressant and 30 tablets of Zyrtec/antiallergy. Pt. #7 was transferred from the Hospital's ED to another Hospital. The clinical record lacked physician certification regarding the medical benefits and risks of transfer.

3. On 11/9/2022 at approximately 11:30 AM, the finding was reviewed with MD #3 (ED Medical Director). MD #3 stated that Pt. #7's psychiatric emergency at the time of transfer was not yet stabilized. MD #3 stated that a certification regarding the medical benefits and risks of the transfer should have been completed. MD #3 could not provide proof that the certification was completed.


C. Based on document review and interview, it was determined that for 3 of 10 patients (Pt. #12, Pt. #13, and Pt. #14) clinical records reviewed for transfer, the Hospital failed to ensure that the medical records related to the emergency condition, which the patients presented, were available and sent at the time of transfer.

Findings include:

1. On 11/9/2022, the Hospital's policy titled, "Emergency Medical Treatment and Transfer" (reviewed by the Hospital on 7/2021) was reviewed and included, "... F... vi... Copies of all medical records available at the time of transfer relating to the emergency condition for which the individual presented shall be sent with the patient to the receiving hospital..."

2. On 11/9/2022, the clinical record of Pt. #12 was reviewed. Pt. #12 was brought to the ED on 9/16/2022 due to seizures. The clinical record indicated that Pt. #12 required a higher level of care necessitating a transfer to another hospital. The clinical record lacked documentation that copies of all pertinent records were sent to the receiving hospital.

3. On 11/9/2022, the clinical record of Pt. #13 was reviewed. Pt. #13 was brought to the Hospital's ED on 9/16/2022 due to a head injury and subdural hematoma (blood clot in the brain). The clinical record indicated that Pt. #13 required a higher level of care necessitating a transfer to another hospital. The clinical record lacked documentation that copies of all pertinent records were sent to the receiving hospital.

4. On 11/9/2022, the clinical record for Pt. #14 was reviewed. Pt. #14 was brought to the Hospital's ED on 11/6/2022 due to altered mental status. The clinical record indicated that Pt. #14 required evaluation and management in another hospital with pediatric services. The clinical record lacked documentation that copies of all pertinent records were sent to the receiving hospital.

5. On 11/9/2022 at approximately 11:45 AM, findings were discussed with E #5 (ED Manager) and MD #3 (Medical Director). E #5 and MD #3 could not provide documentation or proof that copies of all pertinent records were sent to the receiving hospital.