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Tag No.: A2400
Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure compliance with the requirements of 42 CFR ?489.24(b) and/or related requirements of 42 CFR ?489.20(l). The facility further failed to ensure staff compliance with the facility transfer policy.
Findings include:
Review of the Hamot Medical Center Medical Staff Handbook issued September 2010, Part VI Rules and Regulations revealed, "... C. All patients presenting to the emergency department shall receive a medical screening examination in accordance with the Emergency Medical Treatment and Labor Act Policy of Hamot Medical Center (the 'EMTALA Policy'). The provisions of the EMTALA Policy shall govern all patients who are found to have an 'emergency condition', as that term is defined in the EMTALA Policy..."
Review of the Emergency Medical Treatment and Active Labor Act (EMTALA) Policy effective August 17, 2011 and revised November 1, 2010, revealed, "... 3. Transfers From Hamot a) Required Actions When Persons are to Transferred. A person with an emergency medical condition which has not been stabilized may be transferred only if the requirements set forth in 2.f.ii, 2.f.iii or 2.f.iv. have been satisfied. To correctly transfer a patient, Hamot Medical Center must: ... ii. obtain agreement from a receiving facility that it has available space and qualified personnel to treat the person, and that it will accept the transfer ... iv. send to the receiving facility copies of all available medical records related to the emergency medical condition including, but not limited to to records containing observations of signs or symptoms, preliminary diagnosis, treatment provided and test results, together with a signed 'Request for Transfer Prior to Stabilization' form, a 'Physician certification for Emergency Transfers' form, ... v. inform the person (or the person's representative ) of the risks and benefits of the proposed transfer, and must document this and the persons consent in the medical record..."
1. Review of MR1 revealed the patient was examined and treated at UPMC Hamot Emergency Department (ED) for sexual assault and was being transferred for Involuntary Emergency Examination and Treatment. The medical record documented, "Disposition: Transfer to psych facility." Review of the medical record from [Hospital B] revealed the patient arrived by Emergency Medical Services (EMS) from UPMC Hamot. "... Patient admits to suicidal ideation." The clinician history from the medical record at [Hospital B] revealed, "Expresses suicidal ideation. Has definite suicidal thoughts and has a plan..." Further review of the medical records from both hospital failed to reveal any documentation of a ED physician-to-physician contact in order to obtain agreement from the receiving hospital, nor was there any documentation of copies of medical records being sent from the transferring hospital or being received at the receiving hospital.
2. Interview on May 5, 2011, at 10:15 AM with EMP2 confirmed, "I don't see any transfer information in the computer or in that record (copy of MR1's medical record).
3. Review of MR14 revealed the patient was transferred from UPMC Hamot ED to another hospital. There was no documentation that all medical records were sent to the receiving hospital. This was confirmed by EMP1 on May 5, 2011, at 3:05 PM.
4. Review of transfer certification forms on random medical records of transferred patients revealed: no physician transfer certification form to document the risks/benefits of transfer on MR3, MR13, MR16, MR19, and MR20); MR4 listed the benefits and risks of transfer as "acute asthma exacerbation" (the patient's diagnosis); MR5 and MR21 were signed by the physician but the risks and benefits of the transfer were not documented. The above findings were confirmed by EMP1 at the time each was noted on May 5, 2011, between 1:00 and 4:30 PM.
Tag No.: A2409
Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure an appropriate transfer to another facility by failing to notify and assure acceptance of the patient at the receiving facility, by failing to send a copy of all medical records of the individual at the time of transfer for two of 22 patients (MR1 and MR14), and failing to include a signed certification that the medical benefits expected from the transfer of the patient to another facility for treatment outweighed the risks of the transfer and spell out the risks and benefits in 10 of 23 medical records (MR1, MR3, MR4, MR5, MR12, MR13, MR16, MR19, MR20 and MR21) .
Findings include:
Review of the Hamot Medical Center Medical Staff Handbook issued September 2010, Part VI Rules and Regulations revealed, "... C. All patients presenting to the emergency department shall receive a medical screening examination in accordance with the Emergency Medical Treatment and Labor Act Policy of Hamot Medical Center (the 'EMTALA Policy'). The provisions of the EMTALA Policy shall govern all patients who are found to have an 'emergency condition', as that term is defined in the EMTALA Policy..."
Review of the Emergency Medical Treatment and Active Labor Act (EMTALA) Policy effective August 17, 2011 and revised November 1, 2010, revealed, "... 3. Transfers From Hamot a) Required Actions When Persons are to Transferred. A person with an emergency medical condition which has not been stabilized may be transferred only if the requirements set forth in 2.f.ii, 2.f.iii or 2.f.iv. have been satisfied. To correctly transfer a patient, Hamot Medical Center must: ... ii. obtain agreement from a receiving facility that it has available space and qualified personnel to treat the person, and that it will accept the transfer ... iv. send to the receiving facility copies of all available medical records related to the emergency medical condition including, but not limited to to records containing observations of signs or symptoms, preliminary diagnosis, treatment provided and test results, together with a signed 'Request for Transfer Prior to Stabilization' form, a 'Physician certification for Emergency Transfers' form, ... v. inform the person (or the person's representative ) of the risks and benefits of the proposed transfer, and must document this and the persons consent in the medical record..."
1. Review of MR1 revealed the patient was originally seen at UPMC Hamot Emergency Department (ED) with suicidal ideations, but left before being seen by the ED physician. When the patient left the ED without being seen, the hospital notified Crisis, who initiated the Application for Involuntary Emergency Examination and Treatment. Three days later the patient returned to the ED complaining of sexual assault. Following examination and treatment for the sexual assault the medical record indicated, "Disposition: Transfer to psych facility." Review of the medical record from Hospital B revealed the patient arrived by Emergency Medical Services (EMS) from UPMC Hamot. "... Patient admits to suicidal ideation." The Clinician history from the medical record at Hospital B revealed, "Expresses suicidal ideation. Has definite suicidal thoughts and has a plan..." Further review of the medical records from both hospitals failed to reveal any documentation of a ED physician-to-physician contact in order to obtain agreement from the receiving hospital. Additional review revealed that there was no documentation of copies of medical records being sent from the transferring hospital or documentation of the medical records being received at the receiving hospital.
2. Interview on May 5, 2011, at 10:15 AM with EMP2 confirmed the lack of transfer documentation in MR1, "I don't see any transfer information in the computer or in that record [MR1].
3. Interview on May 5, 2011, at 10:50 AM with EMP4 revealed, "[The patient] came in [three days previously] complaining of suicidal ideations ... [The patient] left before I got a chance to talk to [PT1]. I immediately called Crisis and they issued a 302. Crisis kept trying to reach [PT1]. When [PT1] came in this time, I called Crisis to let them know [the patient] was here. [PT1] was here for five or six hours. They [Hospital B] called me that night after the patient arrived there with the police. I would normally get the ED physician to call [Hospital B ED physician]. [The ED physician] was a resident that has not had a lot of experience with it [involuntary evaluation/admission warrants. I set up the wheelchair transport and notified the police and Crisis. I just assumed that Crisis would call [Hospital B] I told EMP7 that everything was taken care of."
4. Interview on May 5, 2011, at 11:05 AM with EMP5 revealed, "[EMP10] was the supervising physician that night. [EMP10] was the one that signed off on it [ED visit] that day." When asked what the role of the supervising physician was EMP5 stated, "The role is that the resident has to come to the supervising physician and present the case. The supervising physician says yea or nay and tells him or her what to do."
5. Interview on May 5, 2011, at 11:45 AM with EMP7 revealed, "The police were involved. I eyeballed [the patient] quickly and the police were with [the patient]. [EMP4] said the patient was a 302 and was medically cleared. Two hours later I received a call from [EMP4] that [Hospital B] had called. Normally I do a doctor to doctor call [for transfers], always. I thought everything was very easy. I thought the prior 302 meant the patient had to go. EMP4 said everything was taken care of. I told [EMP10] that everything was taken care of."
6. Interview on May 5, 2011, at 1:10 PM with EMP10 revealed, "I didn't manually sign off on the chart because that happens. Others often need the chart... I normally review the case immediately after the patient is seen [by the resident]. At the time I saw [the patient] neither [EMP7] nor I knew about the 302. We were dealing with the sexual assault. The 302 was brought to our attention by the police. In my opinion, it wasn't a transfer, I was discharging the patient. I never dealt with anyone with a warrant... It should have been a transfer..."
7. Review of MR14 revealed the patient was transferred from UPMC Hamot ED to another hospital. There was no documentation that all medical records were sent to the receiving hospital. This was confirmed by EMP1 on May 5, 2011, at 3:05 PM.
8. Review of a random sampling of medical records of transferred patients revealed: MR3, MR13, MR16, MR19, and MR20 were missing the physician transfer certification form which document the benefits/risks of the transfer and the patient's consent to transfer; MR4 listed the benefits and risks of transfer as "acute asthma exacerbation" (the patient's diagnosis); MR5 and MR21 were signed by the physician but the risks and benefits of the transfer were blank. The missing documentation was confirmed by EMP1 at the time of the reviews on May 5, 2011, between 1:00 and 4:30 PM.