HospitalInspections.org

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Based on document review and interview, the Governing Body (GB) failed to develop and maintain Education, Policies and Bylaws for the appraisal of emergencies, initial treatment, and referrals.

This failure placed all patients at risk for adverse outcomes.

See Tag A 0093

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Based on document review and interview, the facility lacked:

A) Education of the facility's Emergency Medical Treatment and Labor Act (EMTALA) requirements and obligations as a Recipient Hospital;
B) Policies and procedures (P&Ps) related to the appraisal of emergencies, initial treatment and referrals, when appropriate; and
C) Bylaws that define a response plan for the appraisal of medical emergencies.

Findings for (A) included:

During interviews of Staff H (Admitting Manager), Staff I (Registrar) & Staff J (Registrar) on 8/26/19 at 11:15AM, when asked to describe the EMTALA education they received, each staff member stated that their EMTALA education focused on documentation and processing, such as consents for treatment and insurance. Staff H stated, "I had EMTALA training once, but a refresher would be good."

Review of the Education Files for Staff H, I and J identified the EMTALA Education dated 1/14/19, did not include information on the facility's EMTALA requirements and obligations as a Recipient Hospital.

Review of the Physicians' Credential Files on 8/28/19 revealed that 4 (four) of 4 (four) files lacked evidence of current education/training on the facility's EMTALA requirements and responsibilities as a Recipient Hospital for Staff A (MD/Medical Doctor Psychiatrist), Staff B (MD Psychiatrist), Staff C (Nurse Practitioner Internal Medicine) and Staff D (MD Internal Medicine).

The same lack of education/training was identified for all staff (i.e., Security Officers and Receptionists) who may become the first point of contact for individuals found on hospital grounds seeking medical assistance and admission, as per interview of Staff E (Director of Quality Assurance) on 8/28/19 at 11:40AM. The facility was unable to furnish educational materials that explained the facility's EMTALA requirements and obligations as a Recipient Hospital.

These findings were confirmed with Staff E on 8/28/19 at 11:45AM.
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Findings for (B) included:

Review of the hospital's policy and procedure manual dated 2018-2019, which contained all current admission policies, identified the facility lacked policies or procedures for the following:

i) Inter-Institutional Transfers to Emergency Departments (including) Certification of Patient Transfer and Transfer Summary
ii) Emergency Transport necessity when transporting a patient to another hospital Emergency Department
iii) Escalation Plan for the appraisal of medical emergencies, initial treatment plans and referrals when appropriate
iv) Reporting requirements of inappropriate transfers from (sending) hospitals
v) Retention and maintenance of medical and other records for individuals transferred to or from the hospital (for a period of five years)
vi) Maintenance of a log listing each individual seeking assistance and whether he or she refused treatment or was refused treatment.
vii) Recipient Hospital responsibilities as a participating hospital with specialized capabilities (regardless of whether the hospital has a dedicated emergency department)

These findings were confirmed during interview of Staff E on 8/28/19 at 11:45AM.
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Findings for (C) included:

Review of the Medical Staff Bylaws, Rules and Regulations, last revised 3/28/18, did not identify Providers' responsibilities related to the appraisal of emergencies, initial treatment and referral (when appropriate) and what the facility's EMTALA requirements are as a Recipient Hospital.

These findings were confirmed through interview with Staff E on 8/28/19 at 11:45AM.

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