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Based on policy review, record review, and staff interview, the Hospital failed to ensure compliance with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases, and the related requirements at 42 CFR 489.20 on 3 of 3 days of survey (December 2-4, 2013).

Hospitals are required to adopt and enforce a policy to ensure compliance with the requirements of ?489.24. Failure of the Hospital to adopt and enforce their policies and procedures relating to the Emergency Medical Treatment and Labor Act placed patients at risk of increased anxiety, suffering, distress, and pain related to their reasons for seeking assistance.

Findings include:

The Hospital failed to include the required information in a central log for each individual who comes to the emergency department seeking assistance and failed to accurately document the patient's disposition in the central log (refer to A2405).

The Hospital failed to follow their policies regarding diversion and capacity notification (refer to A2406).

The Hospital failed to document the stability of the patient's condition for patients transferred from the emergency department (refer to A2409).

The Hospital failed to accept an appropriate transfer when the Hospital had the specialized capability and capacity to treat the patient (refer to A2411).

Based on policy review, record review, and staff interview, the Hospital failed to include the required information in a central log for each individual who presented to the emergency department seeking assistance for 11 of 11 months reviewed (January-November 2013) and failed to accurately document the disposition of 1 of 2 patients (Patient #6) who left against medical advice (AMA). Failure to include required information and accurately document in the central log limits the hospital's ability to track the care provided to each individual who presented to the emergency department.

Findings include:

Review of the policy "Standards of Conduct Relating to EMTALA [Emergency Medical Treatment and Labor Act] Compliance C-855" occurred on 12/02/13. This policy, revised 03/13, stated, ". . . 3.3 A central log on each individual who comes to the Dedicated Emergency Department seeking treatment will be maintained. 3.3.1 The central log will indicate whether the individual: 3.3.1.1 refused treatment; 3.3.1.2 was refused treatment and the reason for refusal; 3.3.1.3 was admitted and treated or stabilized and transferred; or 3.3.1.4 was discharged. . . ."

Review of the Hospital's emergency department central log from January through November 2013 occurred on 12/02/13. The entries in the central log for this timeframe did not identify patients the Hospital transferred or stabilized and transferred.

An entry in the emergency department central log for Patient #6 on 09/28/13 indicated the disposition of the patient as an "A" (indicating AMA or against medical advice).

- Review of Patient #6's emergency department record from 09/28/13 indicated the Hospital discharged the patient to home after providing a medical screening exam and treatment. The record did not indicate the patient left against medical advice as documented in the emergency department central log.

During an interview at approximately 1:00 p.m. on 12/03/13, an administrative staff member (#1) confirmed the emergency department's central log did not inaccurately identify the disposition of Patient #6 on 09/28/13.

During an interview at approximately 1:15 p.m. on 12/03/13, an administrative staff member (#1) confirmed the Hospital's emergency department central log did not include whether the Hospital transferred the patient or stabilized and transferred the patient. Staff Member #1 stated the Hospital would include transferred patients in a category of "other." Staff Member #1 stated a determination of whether the Hospital transferred or stabilized and transferred the patients in the "other" category would require a review of the patient's medical record.

Based on policy review, record review, and staff interview, the Hospital failed to follow their policies regarding diversion and capacity notification for 1 of 1 patients (Patient #19) diverted by the Hospital. Failure to follow policies regarding diversion and code capacity places patients at risk of delay in receiving a medical screening examination.

Findings include:

Review of the policy "Code Capacity and Diversion Policy" occurred on 12/03/13. This policy, revised 02/21/11, stated, ". . . Definitions:
Code Capacity - is an internal procedure that allows the mobilization of resources to alleviate an overcrowding issue in order to prevent the organization from going on diversion status.
Diversion - is the closure of the Emergency Department to all incoming transfers through the Emergency Department and the inability to accept incoming ambulance traffic. . . ."

Review of Patient #19's medical record from Hospital B occurred on 12/03/13. The record showed the patient arrived to the Hospital B's emergency department (ED) at 6:30 p.m. on 04/06/13. Review of the ambulance report, dated 04/06/13, stated, ". . . Provider Impression: Altered Level of Consciousness . . . Chief Complaint: Unresponsive . . . Onset Time: [4:30 p.m.] . . . Dispatch Reason: [unconscious/fainting/ineffective breathing] . . . Drop Off Location: [Hospital B] . . . Event Chronology . . . [5:30 p.m.] Incident Onset . . . [6:00 p.m.] Dispatched . . . [6:02 p.m.] At Patient Side . . . [6:03 p.m.] Procedure Performed . . . Procedure. Ventilation . . . Response. Improved . . . Narrative: Responded . . . for a . . . Pt [patient] who was unresponsive Pt was found laying in bed unresponsive breathing at a rate of 6 breaths per [minute] Nursing staff stated that the Pt had last been seen normal at [4:30 p.m.] Pt had been found [5:57 p.m.] unresponsive An oral airway was attempted but Pt began to clench . . . teeth A nasal airway was placed and Pts respirations were assisted with a BVM [bag valve mask] Initial [oxygen] saturation was 71 [percent] with supplemental [oxygen] and ventilation saturation increased to 100 [percent] . . . Pupils were constricted and nonreactive . . . Equal and symmetrical chest rise noted . . . Sanford ER [emergency room] was called and report was given Orders to divert to [Hospital B] were received from [name of nurse] [Name of Hospital B] ER was called and report was given . . . Pt began to open . . . eyes to painful stimulus. Pt also began to moan . . . Pt care was transferred to ER staff . . . without incident . . ."

Patient #19's record contained the emergency room provider's clinical report, dated 04/06/13. The report stated, ". . . The dyspnea is described as severe. . . . The patient has all . . . records at Sanford. [Name of ambulance service] was called for increasing respiratory distress. She was not responding, a nasal airway was placed. They contacted Sanford and communicated a nasal airway was in place. This was confused with a nasal tracheal intubation. Sanford is on diversion for the ICU [intensive care unit], and therefore 'intubated' patients, and thus was diverted to [Name of Hospital B] Emergency Department). . . . Intubation: ED physician at bedside. . . . Disposition: Admitted to Intensive Care Unit. Clinical Impression . . . Acute respiratory failure with hypoxemia and hypercapnia. . . ."

Review of "Capacity Notification Worksheet" records occurred on 12/03/13. A "Capacity Notification Worksheet," dated 04/06/13, stated, "Area Reporting Capacity Limit: ICU [intensive care unit] Date: 4/6/13 Time: 1820 Explanation of Capacity Limit: All ICU Beds full . . . Comments/Notes: 4/7/13 @1025 - off diversion - 1 bed available . . ."

The Hospital provided no evidence the emergency department was on diversion on 04/06/13.

During an interview at approximately 8:15 a.m. on 12/04/13, an administrative staff member (#1) stated the Hospital would not divert patients from the emergency department when a code capacity is in effect for other departments within the Hospital including the ICU. Staff member #1 stated if the ambulance service would call to report on a patient the ambulance service planned to bring to the Hospital's emergency department, the ED staff would tell the ambulance service they could bring the patient to the ED even if the ICU had no available beds. Staff member #1 stated the ED would accept all patients, perform a medical screening exam, and arrange for a transfer if their hospital was at capacity and the physician determined the patient needed hospital admission. Staff member #1 stated he did not recall the Hospital's ED going on diversion this past year.


28086

Based on policy review and record review, the Hospital failed to obtain a written transfer request from the patient indicating the reasons for the transfer request and the patient's awareness of the risks and benefits of the transfer for 1 of 3 patients (Patient #3) transferred from the emergency department (ED) upon the patient's or family's request. Failure to obtain a written transfer request from patients with indication of the patients' awareness of the risks and benefits of transfer limited the Hospital's ability to ensure the quality of care provided.

Findings include:

Review of the policy "Transfers/Discharges To Another Healthcare Facility" occurred on 12/02/13. This policy, revised 06/02/10, stated, ". . . 3. . . . d. Medcenter One [Sanford Medical Center Bismarck] may not transfer a patient with an emergency medical condition that has not been stabilized unless: . . . iii. For transfer on patient request . . . 1. The request is in writing and indicates the reasons for the request. 2. The request indicates that he or she is aware of the risks and benefits of the transfer. 3. The request contains a statement of the Medcenter One's [Sanford Medical Center Bismarck] obligations under EMTALA and the benefits and risks that were outlined to the person signing the request. . . . 5. The request must be made part of the individual's medical record . . ."

- Review of Patient #3's ED record occurred on December 3-4, 2013. The record showed Patient #3 arrived to the Hospital's ED at 10:43 p.m. on 10/17/13. The record indicated the patient's family/Power of Attorney verbally requested a transfer to Hospital B. The record stated the patient's condition upon transfer was unstable and unchanged. The Hospital transferred Patient #3 at 11:42 p.m. by ambulance to Hospital B. The record lacked evidence of a written transfer request from the patient's family/Power of Attorney indicating the reason for the transfer request and the patient's family/Power of Attorney's awareness of the risks and benefits of the transfer.



28086

Based on policy review, record review, and staff interview, the Hospital failed to accept an appropriate transfer from a Critical Access Hospital (CAH) (Hospital C) when the Hospital had the specialized capability and capacity to treat the patient for 1 of 1 patient (#18) record reviewed from a transferring hospital. Failure to accept a patient with needs for services within the capabilities of the Hospital may place the patient at risk for significant decline in condition or delay in treatment.

Findings include:

Review of the policy "Transfers/Discharges to Another Healthcare Facility" occurred on 12/02/13. This policy, revised 06/03/10, stated, ". . . 3. . . . h. Receiving or Recipient Hospital's Responsibilities. A hospital that has specialized capabilities or facilities (e.g., burn unit, shock-trauma units, neonatal intensive care units, or with respect to rural areas, regional referral centers) or is designated as a regional referral center, may not refuse to accept from a referring hospital an appropriate transfer on an individual requiring such specialized capabilities or facilities if the receiving or recipient hospital has the capacity to treat the individual. . . ."

Review of the Code Capacity notification records occurred on 12/03/13. The January 2013 records indicated the Hospital was not at capacity on 01/15/13.

Review of Patient #18's medical record from Hospital C occurred on 12/02/13. The record showed the patient presented to the CAH's emergency room (ER) at 4:15 p.m. on Tuesday, January 15, 2013, with anxiety and aggressive behavior. Review of the provider's ER report stated, "[name of Patient #18] comes to the emergency room tonight. He is found to be very aggressive, he is very confused. He is charging at me in the hallway, he was hitting himself in the head, he is pacing the hallway back and forth. It took me 10-15 minutes to get him in to the actual emergency room. He would say things such as 'I need to be put away' and 'I need to go to the court to explain the case'. Another quote is 'I'm going to die, I can't sit down'. Another quote is 'I'm a mental patient, I'm not a prisoner'. I did ask him if he was okay, if he had been out of medication. He just hit himself and then he soaked his head in water and then violently vomited in the bathroom. He is drinking what appears to be a half a gallon of milk . . . he does have a history of placing bleach inside of his drinks . . . I did call the doctor . . . up to the emergency room so he could evaluate the patient also and he seen the same behaviors that I was seeing and felt he needed to be transferred out. . . . I did call to Sanford, the on call doctor for Psychiatry is [name of psychiatry doctor]. [Name of psychiatry doctor] would not accept [name of Patient #18], said emergency detention is only 24 hours, and that is a waste of their resources because [name of Patient #18] gets down there, he becomes better, and he walks out on them and they are unable to do anything to help him. She did tell me that if I would go to the States Attorney and get a petition that would make him stay there longer then [sic] 24 hours that she would agree to take him. However, I did explain to her that we do not have a States Attorney here every day, the next time the States Attorney would be available would be on Monday, and she said she would not take him without that paperwork, it was a waste of her resources. . . . He continued to be aggressive and very bazar [sic] behaviors. At this point the Sheriffs Deputy did call to Sanford, as he had transferred [name of Patient #18] before, and [name of emergency room doctor] was at the emergency room and he did get on the phone with me and advised me to send him via ambulance to the [emergency room]. I did explain to him that I already talked to [name of psychiatry doctor], [name of psychiatry doctor] did [sic] want to admit him under the fact that he was going to be a waste of her resources, and he said that that was not what he would consider a legal issue at this point because they had open beds and there is no reason they should not be taking him especially since we are unable to care for him here. . . ."

The CAH transferred Patient #18 at 5:31 p.m. mountain time on 01/15/13 by ambulance to Sanford ER. Review of Patient #18's medical record from Sanford ER occurred on 12/02/13. The record identified the patient arrived to the Hospital's ER at 8:02 p.m. central time on 01/15/13 and showed admission to inpatient status for agitation and psychosis after examination. Patient #18's record identified a psychiatry consult due to a history of schizophrenia and for "evaluation and management and to re-start his home medications." Further review of Patient #18's record identified transfer paperwork from the patient's ER visit at Hospital C, including the ER record and corresponding provider and nursing notes, contained in the record. The Hospital did not provide evidence of investigation of this situation.

During an interview at approximately 1:30 p.m. on 12/03/13, two administrative staff members (#1 and #3) stated they were not aware a Hospital physician with psychiatry services had refused to accept the transfer of Patient #18 from Hospital C on 01/15/13. The staff members stated they would expect the Hospital to accept transfers of patients if the Hospital had the capability and capacity to treat the patient.



28086