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Based on observation, interview, and record review, the hospital failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) requirements as evidenced by:

1. Failure to triage patients in a timely manner (refer to A2406).

2. Failure to provide necessary stabilizing treatment for emergency medical conditions (refer to A2407).

3. Failure to document a physician certification enumerating and weighing expected medical benefits and risks of the transfer (refer to A2409).

Based on observation and interview, the hospital failed to post signs regarding patient rights under EMTALA (the Emergency Medical Treatment and Labor Act) in four of nine sampled emergency department (ED) treatment rooms (rooms 13, 14, 24, and 25). In one of three sampled ED patient areas other than treatment rooms (the vertical treatment area or VTA, an area where patients sit in recliners instead of lying on gurneys), the posted sign failed to specify whether the hospital participates in Medicaid. The deficient practices had the potential to cause patients to be unaware of their rights under EMTALA.

Findings:

In observations and interviews during the ED tour on 7/19/21 from 12:47 p.m. to 1:58 p.m., the sign posted in the VTA regarding patient rights under EMTALA did not disclose whether the hospital participates in Medicaid. The Director of Emergency Services (DES) stated there was no EMTALA sign in the VTA, and the posting viewed by the surveyor was an insurance sign. ED treatment rooms 13 and 14 did not contain signs regarding the rights of patients under EMTALA. The DES stated not all ED treatment rooms have the EMTALA sign. ED treatment rooms 24 and 25 did not contain signs regarding the rights of patients under EMTALA. Both rooms had a blank frame mounted on the wall with remnants of tape at each corner of the frame. The DES acknowledged there was no EMTALA sign in room 24 and commented that one could see the stickers where the sign was. The DES stated room 25 was the same.

Based on interview and record review, the hospital failed to consistently provide on-call coverage for the emergency department (ED) commensurate with services available at the hospital. The hospital had ten members (Providers 1 through 10) of its medical staff in obstetrics and gynecology (OB/GYN), nine of which (Providers 1 through 8, and 10) provided routine services at the hospital. Yet the on call schedule for the ED offered OB/GYN coverage only for trauma patients, and a reference sheet regarding the scope of the hospital's services for emergency transfers indicated OB/GYN was not provided. Two of 20 sampled patients (Patients 2 and 7) did receive non-trauma OB/GYN on-call coverage in the ED and one of 20 sampled patients (Patient 1) did not.

Findings:

Review of Patient 1's medical record indicated she was seen at the ED on 7/5/21 complaining of a fever, bleeding, and pain following a hysterectomy (removal of the uterus) at Hospital C on 6/19/21. The "EMERGENCY PROVIDER REPORT" dated 7/5/21 indicated, "I discussed the case with the patient's surgeon [Physician B] who felt that the patient should be treated here at Regional Medical Center however we do not have gyn service on-call. I discussed with our CMO [chief medical officer]... who states that the patient should be transferred ER [emergency room] to ER to [Hospital C] where the patient had the initial surgery for this post op [post-operative] complication. This would be for higher level of care for Gyn services."

Review of the physician on-call schedules provided by the hospital indicated the schedules for the OB/GYN service for January 2021 through July 2021 were labeled "OB/GYN - TRAUMA ONLY". No on-call schedule for non-trauma OB/GYN was provided.

Review of the "Regional Medical Center Reference List" (revised 4/14/21) indicated the document delineated dispositions for various types of patients being considered for transfer in to the hospital. The document indicated OB/GYN was not offered on an on-call basis and that such patients could be declined without escalating to the administrator on call since the service was not offered.

Review of the hospital's undated medical staff roster indicated there were ten members of the medical staff specializing in OB/GYN (Providers 1 through 10), and that Physician B was not a member of the medical staff at the hospital.

In an interview on 7/20/21 at 12:04 p.m., the Director of Medical Staff (DMS) stated the OB service had been closed in April, 2020 and the case volumes of the OB/GYN medical staff had been nil since then. The DMS stated the call schedule for the emergency room was maintained because of trauma. The DMS stated Provider 9 had "ambulatory" status on the medical staff, which was a status pertaining to clinic physicians who do not come to the hospital.

In an interview on 7/20/21 at 12:26 p.m., the Quality Director of Clinical Excellence (QDCE) stated the OB service at the hospital was closed on March 30, 2020 because it was not financially viable due to too few patients. She stated the perinatal unit was taken off the hospital's license on 6/11/21.

Review of a letter from the California Department of Public Health to the QDCE dated 6/8/20 indicated the Neonatal Intensive Care Unit and the perinatal unit were removed from the hospital license effective 5/30/20.

Review of Provider 1's credentials file indicated she was an active member of the medical staff, specialty OB/GYN, last reappointed on 7/1/21 for a two-year term. Provider 1's privileges included (among others) inpatient admitting and attending, core procedural privileges, vaginal and abdominal hysterectomies (removal of the uterus through the vagina or the abdominal wall), laparascopically assisted vaginal hysterectomy (LAVH, using a fiber-optic tube for part of the surgery), and total laparascopic hysterectomy (TLH, using fiber-optic tubes rather than traditional incisions for the surgery). Provider 1's case log for dates of service June 2020 to June 2021 indicated she had performed 5 surgeries and admitted 8 inpatients at the hospital during the time period covered by the report.

Review of Provider 2's credentials file indicated he was an active member of the medical staff, specialty OB/GYN, last reappointed on 7/28/20 for a term expiring on 6/30/22. Provider 2's privileges included (among others) inpatient admitting and attending, core procedural privileges, vaginal and abdominal hysterectomies, LAVH, and TLH. Provider 2's case log for dates of service June 2020 to June 2021 indicated he had performed 29 surgeries and admitted 4 inpatients at the hospital during the time period covered by the report.

Review of Provider 3's credentials file indicated he was an active member of the medical staff, specialty OB/GYN, last reappointed on 1/26/21 for a term expiring on 12/31/22. Provider 3's privileges included (among others) inpatient admitting and attending, core procedural privileges, vaginal and abdominal hysterectomies. Provider 3's case log for dates of service June 2020 to June 2021 indicated he had performed 11 surgeries and admitted 1 inpatient at the hospital during the time period covered by the report.

Review of Provider 4's credentials file indicated she was an active member of the medical staff, specialty OB/GYN, last reappointed on 6/23/20 for a term expiring on 5/31/22. Provider 3's privileges included (among others) inpatient admitting and attending, core procedural privileges, vaginal and abdominal hysterectomies. Provider 4's case log for dates of service June 2020 to June 2021 indicated she had performed 11 surgeries at the hospital during the time period covered by the report.

Review of Provider 5's credentials file indicated he was an active member of the medical staff, specialty OB/GYN, last reappointed on 11/7/19 for a term expiring on 10/31/21. Provider 5's privileges included (among others) inpatient admitting and attending, core procedural privileges, vaginal and abdominal hysterectomies, and LAVH. Provider 5's case log for dates of service June 2020 to June 2021 indicated he had performed 2 surgeries and admitted 15 inpatients at the hospital during the time period covered by the report.

Review of Provider 6's credentials file indicated she was an active member of the medical staff, specialty OB/GYN, last reappointed on 4/1/21 for a two year term. Provider 6's privileges included (among others) inpatient admitting and attending, core procedural privileges, vaginal and abdominal hysterectomies. Provider 6's case log for dates of service June 2020 to June 2021 indicated she had not performed any surgeries or admitted any inpatients at the hospital during the time period covered by the report.

Review of Provider 7's credentials file indicated she was an active member of the medical staff, specialty OB/GYN, last reappointed on 5/1/21 for a two year term. Provider 7's privileges included (among others) inpatient admitting and attending, core procedural privileges, vaginal and abdominal hysterectomies, LAVH, and TLH. Provider 7's case log for dates of service June 2020 to June 2021 indicated he had performed 11 surgeries and admitted 6 inpatients at the hospital during the time period covered by the report.

Review of Provider 8's credentials file indicated he was an active member of the medical staff, specialty OB/GYN, last reappointed on 2/25/20 for a term expiring on 1/31/22. Provider 8's privileges included (among others) inpatient admitting and attending, core procedural privileges, vaginal and abdominal hysterectomies. Provider 8's case log for dates of service June 2020 to June 2021 indicated he had performed 6 surgeries at the hospital during the time period covered by the report.

Review of Provider 9's credentials file indicated she was a member of the medical staff in the ambulatory (outpatient) category, specialty OB/GYN, last reappointed on 1/16/20 for a term expiring on 11/30/21. Provider 9's credentials file indicated she did not have privileges at the hospital.

Review of Provider 10's credentials file indicated he was a courtesy member of the medical staff, specialty OB/GYN, last reappointed on 6/1/21 for a two year term. Provider 10's privileges included (among others) inpatient admitting and attending, core procedural privileges, vaginal and abdominal hysterectomies. Provider 10's case log for dates of service June 2020 to June 2021 indicated he had performed 7 surgeries and admitted 2 inpatients at the hospital during the time period covered by the report.

In an interview on 7/20/21 at 12:42 p.m., the DMS stated OBs were called in to the ED, not only for trauma patients. He stated the OB/GYNs on the medical staff were still doing hysterectomies at the hospital.

Review of Patient 2's medical record indicated she was seen at the ED on 1/26/21. The "EMERGENCY PROVIDER REPORT" dated 1/26/21 indicated, "SHE WAS SENT HERE BY HER OB/GYN TO RULE OUT MISCARRIAGE VERSUS ECTOPIC PREGNANCY." (In an ectopic pregnancy, the embryo attaches outside the uterus. The fetus usually cannot survive, and ectopic pregnancy can cause severe bleeding in the mother.) The provider note did not indicate Patient 2 had any traumatic injuries. The provider note indicated the ED provider consulted Provider 3, an OB/GYN on the hospital's medical staff.

Review of Patient 7's medical record indicated she was seen at the ED on 6/9/21. The "EMERGENCY PROVIDER REPORT" dated 6/9/21 indicated ...Ob was consulted. Advised to initiate therapy for potential pre term labor..." The provider report did not indicate Patient 7 had any traumatic injuries. The provider note indicated the ED provider consulted Provider 1, an OB/GYN on the hospital's medical staff.

In an interview on 7/21/21 at 10:57 a.m., the surveyor asked the QDCE to explain the inconsistent interviews and record reviews regarding OB/GYN on call coverage. The QDCE replied that to her knowledge, OB/GYN on call coverage was only for trauma, but she would have the chief medical officer (CMO) address the question.

In an interview on 7/21/21 at 11:23 a.m., the CMO stated OB provided trauma call for any pregnant trauma patient. She stated the labor & delivery unit at the hospital was closed on 5/3/20. Initially, the OB service supported any pregnant patient, but now on-call OB is only for OB trauma. The CMO stated the hospital has OB/GYNs on its medical staff, who bring patients to the hospital to have surgical procedures, and those patients may be admitted, but the OB/GYNs do not take calls. Regarding Patient 1, the CMO stated anyone who operates cares for their own patients for the first 30 days after surgery. The CMO acknowledged Patient 1's surgeon, Physician B, was not on the medical staff at the hospital, and stated Physician B would not have seen the patient, so the hospital would triage and transfer such a patient. The CMO stated the physicians who had covered the labor and delivery unit had resigned, and the remaining members of the medical staff did not provide consultations on inpatients. When the surveyor asked why Patients 2 and 7, who were not trauma patients, had OB consults while they were in the ED, the CMO replied that OB helps the ED out of courtesy, but they are not on call.

Based on interview and record review, the hospital failed to perform timely triage and medical screening examinations (MSE) for one of 20 sampled patients (Patients 11). This failure had the potential to cause untimely recognition of emergency medical conditions.

Findings:

Review of Patient 11's medical record indicated he arrived in the hospital's emergency department (ED) on 5/29/21 at 1:45 p.m. Patient 11 was seen by a triage nurse 20 minutes later at 2:05 p.m. Patient 11's MSE began at 2:08 p.m., 23 minutes after his arrival.

During an interview on 7/21/21 at 3:19 p.m., the emergency department manager (EDM) confirmed Patient 11's triage and MSE were delayed.

Review of the hospital's policy, "TRIAGE IN THE EMERGENCY DEPARTMENT," reviewed 6/20/12 indicated rapid assessment, the dynamic process of sorting, prioritizing and assessing the patient will be done within 10 minutes of arrival.

Based on interview record review, the hospital failed to provide necessary stabilizing treatment for emergency medical conditions, for two of 20 patients (Patients 6 and 9), before they were transferred to other hospitals due to their insurance reasons. This failure had the potential to delay necessary treatment of patients with emergency medical conditions.

Findings:

1. Review of Patient 6's Emergency Provider Report, dated 5/31/21 at 11:22 a.m., indicated the patient was a 45-year-old female, with history of hypertension (HTN, high blood pressure) and diabetes (a metabolic disease that causes high blood sugar), and transferred from another hospital (Hospital A) for high level of care for stroke (a serious life-threatening medical condition that happens when the blood supply to part of the brain is cut off resulting in injury to the brain due to absence of blood flow and oxygen). It indicated the patient woke up at 8:20 a.m. on that day when she felt sudden onset of sharp headache with associated right arm and right leg weakness. At Hospital A, the computerized tomography (CT, a medical imaging technique used in radiology to get detailed images of the body noninvasively for diagnostic purposes) reading showed left superior (situated upper) cerebellar (relating to the part of the brain at the back of the skull in vertebrates, which coordinates and regulates muscular activity) hemorrhage (an escape of blood from a ruptured blood vessel) and the computed tomography angiography (CTA, a type of medical test that combines a CT scan with an injection of a special dye to produce pictures of blood vessels and tissues in a part of the body) result showed questionable occlusion in right posterior (back in position) inferior (lower) cerebral (of or relating to the brain) artery (blood vessels that deliver oxygen-rich blood from the heart to the tissues of the body).

On the same report, Review of Systems (ROS) indicated the patient showed right arm weakness and the physical exam indicated the patient had mild weakness to right upper extremity. Review of the CT result, dated 5/31/21 at 11:46 a.m., indicated the impression was mild chronic changes without acute intracranial (within the skull) hemorrhage. ED course indicated the patient received medications including Aspirin 325 mg (blood thinner) by mouth and Levetiracetam (anticonvulsant) IV (intravenously), and laboratory tests and electrocardiogram (ECG,a test for electrical activity of the heart) check were performed.

Review of Free Text MDM (Medical Decision Making) Notes indicated the patient presented with symptoms "concerning for acute CVA [stroke] versus TIA [transient ischemic attack or also called mini stroke, a temporary disruption in the blood supply to part of the brain]". It indicated the ED (emergency department) provider discussed the patient care with a neurointerventional radiologist and the patient was deemed to not be an interventional candidate. It indicated the "patient's insurance as with [Hospital B] and case was discussed with [Hospital B] transferring facility who will accept the patient at this time." It further indicated the primary impression was CVA and the secondary impressions were left leg weakness, numbness and tingling of right arm, and right arm weakness. It indicated "Transfer Reason" was "insurance."

Review of Patient 6's EMTALA MEMORANDUM OF TRANSFER, dated 5/31/21 at 6:31 p.m., indicated the diagnosis for the transfer was "TIA", the reason for transfer was "Medically Indicated", and the question if the "Patient Requested" was unmarked. Under the section of "RISKS AND BENEFITS FOR TRANSFER", for medical benefits, the physician marked as the transfer was to "Obtain level of care/service unavailable at this facility" and the service was "Neurology."

During an interview on 7/21/21 on 11:25 a.m., the chief medical officer (CMO) stated Patient 6 was transferred when the patient was stable. She stated when the patient has Hospital B's insurance, Hospital B requests to transfer the patient to its hospital. She reviewed Patient 6's Emergency Provider Report and stated there was no document Hospital B or the patient requested the transfer. CMS stated if the patient did not have Hospital B's insurance, there was no reason to transfer the patient to Hospital B because the hospital could provide high level of neurology services.

Review of the UpToDate (an online medical reference) article, "Initial evaluation and management of transient ischemic attack and minor ischemic stroke", updated 4/30/21, indicated TIA is a neurologic emergency because patients with a time-based TIA (i.e., symptoms lasting less than 24 hours) or minor, nondisabling ischemic stroke are at increased risk of recurrent and potentially disabling ischemic stroke, especially in the days following the index event. Accumulating evidence suggests that immediate intervention after a TIA or minor, nondisabling ischemic stroke can reduce the risk of recurrent stroke compared with delayed intervention. For patients who present with TIA or minor ischemic stroke, implementation of appropriate diagnostic evaluation and stroke prevention treatment should proceed without delay, preferably within one day of the ischemic event. Urgent evaluation of suspected TIA and minor, nondisabling ischemic stroke is necessary for confirming the diagnosis of TIA or ischemic stroke, excluding stroke mimics, and determining the ischemic mechanism, which has important implications for directing targeted treatment for secondary stroke prevention. The evaluation includes urgent brain imaging, vascular imaging, a cardiac evaluation, and laboratory testing (algorithm 2). The evaluation proceeds in tandem with initiation of antiplatelet therapy; both should be implemented without delay, preferably within one day of the ischemic event.



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2. Review of Patient 9's Emergency Provider Report, dated 7/10/21 indicated Patient 9 was a 40 year old female with a history of HTN, diabetes, and congestive heart failure (CHF, condition when the heart cannot pump blood efficiently). Patient 9 presented with shortness of breath (SOB) "after running out of lasix [medication to treat extra fluid in body] 5 days ago." The CT reading showed interval development of small right pleural effusion [buildup of fluid between lungs and chest wall] since 6/27/21 and interval development of small ascites [buildup of fluid in the abdomen] and body wall edema [swelling caused by excess fluid] since the prior exam of 6/27/21. Patient 9's clinical impression (problem) was CHF exacerbation.

Review of the Free Text MDM Notes indicated Patient 9's symptoms improved after lasix. Patient 9 was discharged "in stable condition" and given a prescription of lasix.

Review of Patient 9's Emergency Provider Report, dated 7/12/21 indicated Patient 9 presented with constant, moderate SOB, vomiting and intermittent cough with phlegm. Patient 9 "has not been able to take lasix for her CHF because she is having trouble filling her prescription." An X-ray reading showed "mild vascular congestion, possibly positional in etiology."

Review of Patient 9's Free Text MDM Notes indicated, "She [Patient 9] has been out of her Lasix for a couple weeks. Patient was given Lasix... We did ambulate the patient without oxygen. It was noted that her oxygen level did stay above 95% however her heart rate quickly became tachycardic [fast heart rate]. She reported subjective shortness of breath at this time. Given her continued symptoms and her vital sign abnormalities I do believe that she requires admission for further IV [intravenous] Lasix and evaluation. Patient ... will be transferred to [Hospital D]." There was no documentation that indicated the reason Patient 9 was not admitted to this hospital.

Review of Patient 9's EMTALA MEMORANDUM OF TRANSFER, dated 7/12/21 indicated the diagnosis for the transfer was "CHF exacerbation," the reason for tranfer was "Medically Indicated." Under the section "RISKS AND BENEFITS FOR TRANSFER," for medical benefits, the physician marked the transfer was to "obtain level of care/service unavailable at this facility." The area to indicate which "service" was unavailable was left blank.

During an interview on 7/21/21 at 11:35 a.m., the CMO stated the hospital was able to treat a patient with congestive heart failure.

During an interview on 7/21/21 at 3:25 p.m., the Director of Emergency Services (DES) stated if a provider determines a patient needs to be admitted, they look at the patient's insurance and let the unit clerk know. Then they notify the hospital under the patient's insurance and initiate transfer.

Based on interview and record review, the hospital failed to ensure one of 20 patients' (Patient 1) medical records contained a physician certification (a documentation indicating that a physician certifies the expected medical benefits of the transfer outweigh the increased risks that results from being transferred) or document specifying the expected benefits of the transfer and risks associated with the transfer. This failure had a potential to deprive patients of information necessary to make informed decisions about their treatment and transfer and could cause an unnecessary transfer with unspecified reasons of the transfer.

Findings:

Review of Patient 1's Emergency Provider Report, dated 7/5/21, indicated the patient was a 51-year-old female, with past history of hysterectomy (surgery to remove a woman's uterus [the place where a baby grows when a woman is pregnant]) on 6/19/2 in Hospital C, and presented to the ED (emergency department) complaining of bleeding from the post-op (postoperative) site on the abdomen and associated abdominal pain.

On the same report, Review of Free Text MDM (Medical Decision Making) Notes indicated at 2:58 p.m., Physician A re-evaluated Patient 1 and "some pus was also expressed from the wound." Physician A discussed Patient 1's care with Patient 1's surgeon in Hospital C, "who felt that the patient should be treated here at [the hospital name] however we do not have gyn [gynecology, the branch of physiology and medicine which deals with the functions and diseases specific to women and girls, especially those affecting the reproductive system] service on-call." It indicated Physician A discussed with the chief medical officer (CMO) and the CMO stated the patient should be transferred to Hospital C where the patient had the initial surgery for the post-op complication and "this would be for higher level of care for Gyn services." At 5:30 p.m. Physician A discussed the case with a doctor who accepted the patient in transfer to Hospital C for higher level of care for gynecology services. There was no documentation regarding the expected medical benefits and risks associated with transfer and/or whether the benefits outweighed the risks.

Review of Patient 1's Emergency Patient Record, dated 7/5/21, indicated at 7:10 p.m. Patient 1 was transferred to Hospital C. There was no physician certification indicating the physician certified that the expected benefits of the transfer outweighed the risks.

Review of the hospital's Memorandum of Transfer, a transfer form utilized in the hospital, indicated the form certified the risk and benefits of the transfer, verification of health records being sent, accepting physician, and certification whether the patient was in stable condition.

During an interview on 7/19/21 at 2:10 p.m., Quality Director of Clinical Excellence (QDCE) stated when a patient is transferred to another hospital, the physician has to fill the form, Memorandum of Transfer. She reviewed Patient 1's medical records and stated Patient 1's record did not contain Memorandum of Transfer form.

Review of the hospital's policy, "EMTALA-CALIFORNIA TRANSFER POLICY", dated 11/2016, indicated any transfer of an individual with an emergency medical condition must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual's behalf, or by a physician order with the appropriate physician certification as required under EMTALA. It indicated a physician must sign an express written certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual. The certification should meet the following requirements: 1) The certification must state the reason for transfer. The narrative rationale need not be a lengthy discussion of the individual's medical condition as this can be found in the medical record but should be specific to the condition of the patient upon transfer. 2) The certification must contain a complete picture of the benefits to be expected from appropriate care at the receiving facility and the risks associated with the transfer, including the time away from an acute care setting necessary to effect the transfer. 3) The date and time of the physician certification should closely match the date and time of the transfer. 4) Certifications may not be backdated. It further indicated a Memorandum of Transfer must be completed for every patient who is transferred to anther separately licensed hospital. A copy of the Memorandum of Transfer shall be retained by the transferring hospital and incorporated into the patient's medical record.

Review of the hospital's policy,"EMERGENCY DEPARTMENT PATIENT TRANSFER PROCESS", dated 4/9/31, indicated the physician completes the Physician Section of the Memorandum of Transfer (MOT) form after reviewing all ordered tests and treatments and stabilizing the patient and certifies the patient status for transfer by signing the certification. The primary care nurse completes the nursing section of the MOT form.