HospitalInspections.org

Based on observation, interviews, documentation reviewed in 3 of 12 ED records for patients (Patients 1, 3 and 12), who presented to the hospital's ED who were transferred to other facilities for stabilizing treatment, and review of hospital policies and procedures, it was determined the hospital failed to fully develop and enforce appropriate EMTALA policies and procedures related to the provision of appropriate transfers, reporting of suspected incidences of inappropriate transfers, and posting of EMTALA signage.

Findings include:

1. Review of hospital policies and procedures revealed no evidence that the following required EMTALA subject was addressed:

a. Reporting of suspected incidents of inappropriate transfers.

2. Review of hospital policies and procedures revealed that the hospital failed to fully develop and implement policies and procedures in the following areas:

a. Appropriate Transfer: Refer to the findings identified under Tag A2409, CFR 489.24(e)(2)(1-2), which reflects the hospital's failure to effect appropriate transfers for patients who presented to the ED and were transferred to other facilities for stabilizing treatment.

b. Posting of Signs: Refer to findings identified under Tag A2402, CFR 489.20(q), which reflects the hospital's failure to ensure the posting of the required EMTALA signs.

Based on observation, interview, and review of policies and procedures, it was determined that the hospital failed to fully to develop and implement a policy and procedure for the posting of the required EMTALA signs, and failed to post the required EMTALA signs in all places likely to be noticed by individuals entering the ED as required by this regulation.

Findings include:

1. A tour of the ED was conducted on 01/21/2014 at 1415 with the ER Director. The ambulance entrance and adjacent hallway used by patients entering the ED was observed. For patients arriving by ambulance, there was no EMTALA signage posted in these areas.

2. An interview was conducted on 01/21/2014 at 1420 with the ER Director. He/she confirmed that the the required EMTALA signage was not posted in the ambulance entrance or the adjacent hallway. The ER Director stated that there were no EMTALA signs posted in any of the ED patient treatment rooms. He/she further acknowledged that patients entering the ED by ambulance would not have an opportunity to see any EMTALA signage during their ED visit.

3. Review of the hospital's policy and procedure titled "Patient Rights and Consent to Transfer," last reviewed 06/2011 reflected "The hospital will post the required signs in the Emergency Department and the Obstetrical Department. The sign will specify the rights of persons to emergency treatment as required by the Secretary of Health and Human Services and notification of whether or not the hospital participates in Medicaid." The procedure did not identify the specific locations where the EMTALA signs were to be placed to ensure they were posted in places likely to be noticed by all individuals entering the ED.

Based on interviews, documentation reviewed in 3 of 12 ED records of patients (Patients 1, 3 and 12), who presented to the hospital's ED who were transferred to other facilities for stabilizing treatment, and review of hospital policies and procedures, it was determined that the hospital failed to effect appropriate transfers of those individuals. The hospital failed to ensure that the receiving hospital had available space and had agreed to accept the transfer of the individual; the hospital failed to ensure that the transfer was effected through qualified personnel and transportation equipment; and the hospital failed to ensure the required physician certification that the benefits of the transfer outweighed the risks of transfer in all cases. However, for Patient 1, the hospital had identified its failure to ensure the receiving hospital had available space and had agreed to accept the transfer of the individual, had conducted an analysis, and had initiated steps to address the failure.

Findings include:

1. The ED record for Patient 1 was reviewed. Documentation on the "ER Summary" reflected the patient presented to the ED by ambulance on 01/03/2014 at 1102.

Documentation by the RN recorded at 1114 reflected that the patient had arrived restless, unable to speak clearly, vomiting bile and phlegm, and had not taken his/her Klonopin (an anticonvulsant medication used to treat seizures and panic disorder) for 5 days.

The 1122 "ER Summary" notes documented by the RN reflected "...[Patient] appears manic and anxious with noted [rapid breathing] shallow respirations and uncontrollable upper/lower [extremity] movement. [Patient] states [he/she] is out of [his/her] klonopin and has had similar symptoms when [he/she] has been out before."

The "ER Physician Documentation" reflected the patient was seen by the physician at 1132. The patient's chief complaint was recorded as nausea, vomiting and diarrhea. The documentation reflected that the patient was "disoriented [to time, place, and person]", had auditory and visual hallucinations, and was not able to answer questions coherently.

The 1132 "ER Triage Assessment" notes documented by the RN reflected that the patient's blood pressure was elevated at 195/124.

The 1412 "ER Summary" notes documented by the RN reflected "Patient vomited over side rails on the floor."

The 1700 "ER Summary" notes documented by the RN reflected the patient's blood pressure was elevated at 189/120.

The 1941 "ER Summary" notes documented by the RN reflected the patient's blood pressure was elevated at 189/106.

The 1944 "ER Summary" notes documented by the RN reflected that the patient vomited.

"ER Physician Documentation" notes reflected oral Clonidine HCl (a medication used to treat high blood pressure) was administered to the patient at 2015.

The 2045 "ER Summary" notes documented by the RN reflected "...Patient frequently speaking about hallucinations. Patient vital signs rechecked, blood pressure 210/119."

The 2123 "ER Summary" notes documented by the RN reflected "[Patient] leaned over bedrails and vomited on floor."

The 2133 "ER Summary" notes documented by the RN reflected that the patient's blood pressure was elevated at 211/138.

"ER Physician Documentation" notes reflected that oral Clonidine HCl was administered to the patient at 2146.

The 2209 "ER Summary" notes documented by the RN reflected that the patient's blood pressure was elevated at 184/100.

The 2234 "ER Summary notes documented by the RN reflected that "Patient departed. Patient ambulated out of emergency department independently while holding hand of this nurse and [secure transport company] staff member...frequently chattering about objects and persons that are not present."

The 2241 "ER Discharge Assessment" notes documented by the RN reflected that the patient's blood pressure at the time of discharge continued to be elevated at 184/110, and that "Patient transferred to [Hospital 1] in Eugene, Oregon for mental health placement. Transfer and transport was initiated by [mental health crisis worker]...Patient transfer in to transport vehicle."

Documentation on the "Crisis Contact Note" by the mental health crisis worker was dated 01/03/2014 and not timed. The notes reflected "Client was brought to the ER by ambulance...due to concerns about...psychotic behaviors...client was not cooperative and would not remove [him/herself] from the floor...Client was confused and not oriented as to where [he/she] was or the date. [His/her] memory was impaired...Client does not possess adequate judgement or insight...Client's ability to meet [his/her] own needs is gravely compromised. Efforts to coordinate care with Lane County Mental Health were unsuccessful. This writer arranged for transportation to transport client to [Hospital 1] ER in Eugene..."

The "ER Physician Documentation Assessment and Plan" identified the "Diagnosis Primary Impression" as "Acute Psychosis". A note recorded under "Comments" reflected "I have not had any communications with an accepting facility prior to hand off." The note was dated and timed as 01/03/2014 at "11:32".

A form titled "Transfer Requirements Condition and Orders" was signed, but not dated or timed by the physician. The form was additionally signed by an RN and the date and time recorded by the RN was 01/03/2014 at 2213. The RN recorded the patient's blood pressure on the form as 184/110. Section "1" of the form reflected that "The receiving physician has agreed to accept transfer and to provide appropriate medical treatment as acknowledged by: Crisis Team - [Hospital 1] Date/Time: 1/3/14 @ 2132." Section "2" of the form reflected that "The receiving facility, [Hospital 1], has available space and qualified personnel to accept transfer for medical treatment as acknowledged by: [mental health crisis worker] Date/Time: 1/3/14 @ 2132. RN to RN Report: No RN available to give report to..." The patients "Diagnosis" was recorded as "Acute Psychosis". Documentation on the form reflected that the patient was being transferred via "Private Care...Secure Tx [sic]". The following sections of the form were blank: "Personnel required" for transport, "Required Life Support Equipment", "Treatment enroute", and "Medical direction to be provided by".

There was no documentation to reflect the identity of any physician, RN, or other individual at Hospital 1 who had accepted the patient for transfer or who had received any report about the patient. There was no documentation to reflect that the mode of transportation, and the number and qualifications of personnel accompanying the patient during transport, was appropriate for this patient experiencing acute psychosis, elevated blood pressure, and recurring vomiting.

A form titled "Patient Rights & Consent To Transfer" was signed, but not dated or timed by the physician. The section on the form for "Benefits of Transfer" included no patient specific benefits and was blank. The section on the form for "Medical Risks Include" had no patient specific risks identified and contained only an illegible entry in that space. The form lacked documentation to reflect that the physician had certified the benefits of transfer outweighed the risks of transfer prior to the patient's transfer.

An interview was conducted with the ED physician on 01/23/2014 at 0850. The physician indicated he/she was on duty in the ED on 01/03/2014 when Patient 1 was transferred to Hospital 1. He/she stated that the patient was already in the ED when he/she arrived at approximately 2000. The physician stated the patient presented to the ED with acute psychosis and "had elevated blood pressures." The physician stated that the mental health crisis worker in the ED had found placement for the patient "somewhere," but acknowledged during the interview that he/she did not know where the patient was going or whether or not the patient was being transferred to a hospital or another type of facility. The physician further acknowledged that he/she had no communication with a physician at Hospital 1 regarding the patient. The physician stated there usually was no physician to physician communication for "psych patients," and stated that the transfer arrangements for "psych" patients were handled by the mental health crisis workers. The physician stated that the patient needed inpatient psychiatric services and stated "[He/she] needed help." The physician stated "This was a mistake. It shouldn't have happened," and "If I'd known [he/she] was going to a hospital, I would've asked more questions."

During the interview, the physician reviewed Patient 1's ED record. The physician stated he/she signed the physician certification on 01/03/2014, and acknowledged the documentation on the certification lacked a date and time the certification was signed, and had an illegible entry on the section of the form designed to list the medical risks of the patient's transfer.

An interview was conducted on 01/22/2014 at 1330 with the ED nurse who was assigned to care for Patient 1 when the patient was transferred to Hospital 1. The nurse stated that Patient 1's blood pressure had been elevated, and that the patient had been vomiting and hallucinating during the ED visit. The nurse stated the usual process for transferring a patient included a nurse to nurse report with a nurse at the receiving hospital. The nurse indicated he/she did not give a nurse to nurse report for Patient 1's transfer, and stated that based on information he/she received from the mental health crisis worker, "I didn't think it was necessary. I thought [Patient 1] was going there [Hospital 1 ED] to see the crisis team and not the staff in the ED." He/she further stated that he/she did not communicate with anyone at Hospital 1 prior to the patient's transfer, and did not know if Hospital 1 had an available bed, or an accepting physician. The nurse indicated that he/she received a phone call on 01/04/2014 at about 0400 from an ED nurse at Hospital 1. The ED nurse from Hospital 1 told the nurse that they did not know the patient was coming, had not received a nurse report, and was concerned that this was an EMTALA violation because the patient's blood pressure was elevated and the patient was "disorganized."

An interview was conducted on 01/22/2014 at 1600 with the ED mental health crisis worker. The crisis worker indicated that he/she evaluated Patient 1 and stated it was clear the patient was having a psychotic episode. He/she stated that after seeing the patient, he/she knew that the patient needed to be admitted "somewhere." The crisis worker stated he/she called Hospital 1 and spoke with "someone in admissions", who told him/her that the hospital could not admit the patient, and that he/she should call back in the morning. The crisis worker stated that he/she then called his/her supervisor, told the supervisor that Hospital 1 could not accept the patient, and asked the supervisor for direction. The crisis worker stated that the supervisor told him/her to facilitate transfer of the patient to Hospital 1's ED so the crisis team for Lane County could get the patient admitted to an inpatient facility. The crisis worker stated he/she made transportation arrangements to transfer Patient 1 by "secure transport" to Hospital 1's ED. The crisis worker indicated he/she knew when the patient was transferred to Hospital 1 that the hospital did not have an accepting physician or an available bed for the patient, and acknowledged during the interview that the hospital had not accepted the patient for transfer. The crisis worker also acknowledged during the interview that he/she had never received any EMTALA training from the hospital.

An interview was conducted on 01/23/2014 at 0840 with the mental health crisis worker's supervisor. The supervisor confirmed that he/she directed the crisis worker to arrange for the transfer of Patient 1 to Hospital 1. The supervisor acknowledged that he/she knew that Hospital 1 did not have an available bed for the patient when the patient was transferred.

An interview was conducted on 01/24/2014 at 1150 with the ER Director. He/she stated that Patient 1 was transported to Hospital 1 by "secure transport," which was a vehicle that locked the patient into the back seat, and had barriers separating the back seat from the other areas of the vehicle. The ER Director stated that the driver of the transport vehicle was the only person who went with the patient during the the transfer to Hospital 1. The director stated the transport vehicle was not equipped with any medical equipment. He/she was asked if the driver of the vehicle had any medical training or other qualifications such as BLS, and he/she stated "I don't know. My guess would be no." He/she stated the driver was "usually" a mental health worker or a crisis worker and stated, "They're not medical people at all. I don't know of any protocol they have for dealing with a medical emergency, but in the past they've stopped at a medical center along the way to get assistance." (According to mapquest.com driving directions, the distance from Good Shepherd Medical Center to Hospital 1 is 298.06 miles; and the driving time is 4 hours and 59 minutes)

2. The ED record for Patient 3 was reviewed. Documentation on the "Emergency Department Daily Census Log" reflected that the patient presented to the ED on 01/08/2014 with a check in time of 1954. The "ER Physician Documentation" reflected the patient was seen by the physician at 2005. The chief complaint was documented as "Medical Clearance." Physician documentation further reflected "...Patient has been noncompliant [sic] medications for the past 6 weeks. [He/she] actually jumped off the Burnside Bridge in Portland one month ago...[He/she had an appointment today for commitment hearing...but managed to get away...the patient has been threatening suicide...
Timing/Duration: getting worse
Presents with: bizarre behavior, unclear thinking, violence
Medication Compliance: No
Suicidal/Homicidal Ideation: Yes
Quality: hallucinations, auditory..."

The "Departure" section of the "ER Summary" notes reflected
"Primary Impression:
acute on [sic] chronic psychosis
Secondary Impressions:
acute suicidality"
The notes further reflected that the patient was transferred on 01/09/2014 at 1510.

The 01/09/2014 discharge assessment documented by the RN at 1550 reflected "...[Patient] walks out in cuffs to patrol car with 5 officers at side. [Patient] does not resist but yelling loudly and persistently. [Patient] to be transported to...psychiatric emergency facility."

The physician certification form titled "Patient Rights & Consent To Transfer" was reviewed. The section on the form for "Benefits of Transfer:", "Risks of Transfer:", and "Medical Risks Include:" were blank and included no patient specific risks or benefits. The "Physical [sic] Certification - Practitioner Initiated" section on the form reflected an electronic signature dated 01/10/2014 at 1545 (the day after the patient was transferred). The record lacked documentation that a physician had signed a certification that the medical benefits of the transfer outweighed the increased risks to the patient.

An interview was conducted with the ER Director on 01/23/2014 at 1500. The ER Director reviewed Patient 3's medical record and confirmed that the risks and benefits of the transfer were not documented.

3. The ED record for Patient 12 was reviewed. Documentation on the "Emergency Department Daily Census Log" reflected the patient presented to the ED on 09/01/2013 with a check in time of 0443. The "ER Physician Documentation" reflected the patient's chief complaint was "Light Headed And Chest Pain." Physician documentation further reflected that the patient had gone to a family member's house and threatened to kill the family member.

Documentation on the 09/01/2013 "Crisis Contact Note" reflected "Unable to care [sic]. Death Threats against [his/her] kids. Being sent to Juniper Ridge Acute Care Center - J & R Secure Transport."

The 1538 "ER Discharge Assessment" documented by the RN reflected "[Patient] was transferred to juniper ridge in john day via j&r secure transport."

The physician certification form titled "Patient Rights & Consent To Transfer" was reviewed. The section on the form for "Benefits of Transfer:", "Risks of Transfer:", and "Medical Risks Include:" were blank and included no patient specific risks or benefits. The physician signature line was blank for the "Physical [sic] Certification - Practitioner Initiated" section on the form. The record lacked documentation that a physician had signed a certification that the medical benefits of the transfer outweighed the increased risks to the patient.

An interview was conducted with the ER Director on 01/23/2014 at 1505. The ER Director reviewed Patient 12's medical record and confirmed that the risks and benefits of the transfer were not documented. The ER Director indicated during the interview that the reason the risks and benefits were not documented was because the patient was not oriented, and because the transfer was court ordered.

4. Review of the hospital's Emergency Care Department policy and procedure titled "Responsibility for patients During Interfacility Transfers," last reviewed 06/2011 reflected the following requirements: "...A patient shall be transferred in a safe and timely manner according to his/her medical condition and accompanied by personnel whose training meets the medical needs of the patient during transfer to another facility...
-The transferring physician shall be responsible for determining the medical need for transfer and for arranging the transfer.
-The patient shall not be transferred to another facility until the receiving hospital and physician consent to accept the patient.
-The transferring physician retains responsibility for the patient until care is assumed at the receiving hospital."

Review of the hospital's Emergency Care Department policy and procedure titled "Patient Rights and Consent to Transfer," last reviewed 06/2011 reflected the following requirements:
"3. APPROPRIATE TRANSFER
To qualify, the receiving facility must have available space and qualified personnel for the treatment of the patient AND agree to accept the patient in transfer and to provide appropriate medical treatment. The transferring hospital must provide the receiving hospital with all medical records available that relate to transfer, including...the informed written consent, the certification (Physician Initiated Transfer, Certificate of Transfer)"...
4. CERTIFICATION FOR TRANSFER
A physician (Emergency or Attending Physician) must sign a certification that, based on the information available at the time of transfer, the medical benefits of transfer to another medical facility outweigh the risks of transfer to the patient, including an unborn child, as applicable. The certification must contain pertinent findings, that the decision to transfer is based on information available at the time of transfer and a summary of the medical benefits expected by transfer outweigh the increased risk of the patient, and unborn child, as applicable..."