HospitalInspections.org

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Based on staff interviews, review of medical records, and review of hospital policies and procedures, the hospital failed to adopt and implement policies and procedures for evaluation, treatment, and transfer of patients presenting for emergency care in accordance with Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

Failure to ensure that patients are made aware of the risks of and alternatives to receiving medical treatment or transferring to another facility decreases their ability to make informed decisions and places patients at risk of harm, including death.

Findings included:

1. Failure to obtain, or attempt to obtain, the written refusal of care for 2 of 5 patients leaving against medical advice (AMA) (Patient #5 and Patient #24).

Cross Reference: A2407

2. Failure to ensure that the medical records contained a physician certification showing that the medical benefits of transfer reasonably outweighed the risks of being transferred, or documentation that the patient requested the transfer after being made aware of the risks and benefits of the transfer for 1 of 10 patients transferred to other hospitals (Patient #4).

Cross Reference: A2409
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Based on interview, document review and review of hospital policies and procedures, the hospital failed to obtain, or attempt to obtain, a written refusal of care for 2 of 5 patients leaving against medical advice (AMA) (Patient #5 and Patient #24).

Failure to obtain written refusal for care or treatment may impact the patient's ability to make informed decisions including the risks of and alternatives to leaving and places patients at risk for injury or death.

Findings included:

1. Review of the hospital's policy titled, "Leaving Against Medical Advice (AMA)," policy ID 9365789, approved 06/21, showed that if a patient chooses to leave AMA, the attending provider or primary nurse will attempt to obtain the patient's signature on the AMA Patient Acknowledgement Form. If the patient refuses to sign the form, the caregiver will mark through the signature line and write, "patient/representative refused to sign." The caregiver will sign, date and time the form.

2. Review of the medical record showed that on 05/07/23, Patient #5 refused to complete treatment for suicide ideations, but staff observed the patient sitting in the emergency department lobby for 2 hours while waiting for a taxi. The investigator found no evidence of an AMA Patient Acknowledgement Form in the patient's medical record.

3. Medical record review showed that on 09/03/23, Patient #24 refused to complete treatment for a small bowel obstruction. The investigator found no evidence of an AMA Patient Acknowledgement Form in the patient's medical record.

4. On 10/18/23 at 3:30 PM, the investigator interviewed the ED Assistant Nurse Manager (Staff #1). During the interview, Staff #1 confirmed the investigator's findings of the missing AMA Patient Acknowledgement Forms for Patient #5 and Patient #24.
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Based on staff interviews, review of clinical records, and review of hospital policies and procedures, the hospital failed to ensure that the medical records contained a physician certification showing that the medical benefits of transfer reasonably outweighed the risks of being transferred, or documentation that the patient requested the transfer after being made aware of the risks and benefits of the transfer for 1 of 10 patients transferred to other hospitals (Patient #4).

Failure to obtain physician certification for transfer or ensure that patients are made aware of the risks and benefits of transferring to another hospital has the potential to deprive patients of information necessary to make informed decisions about treatment and transfer and places patients at risk for unnecessary transfer.

Findings included:

1. Review of the hospital document titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," policy ID 13357389, approved 06/16/23, showed that when transferring the patient to another facility is necessary, the physician completes an EMTALA Transfer Form to document:

a. A description and reason for the proposed transfer.

b. The consent, request, or refusal of transfer by the patient or legal representative.

c. Physician's written certification that the physician explained the specific risks and benefits of the transfer with the patient.

d. The name of the accepting facility and physician.

2. Review of Patient #4's medical record showed that on 05/05/23 at 8:45 AM, the patient arrived in the Emergency Department (ED). At 8:53 AM, the ED nurse triage notes showed that Patient #4 was 9 months pregnant with a due date of 05/12/23 but was having contractions that started during the night. The patient stated that the labor pains were different than with her 2 previous deliveries.

Provider documentation showed that Patient #4 was about 5 cm dilated and the fetal head was felt 3 cm from the vaginal opening, but there was no water break or bloody show yet. The patient was supposed to deliver her baby at a different hospital, and the provider contacted a physician at the other facility who agreed to the transfer.

At 9:11 AM, the patient left the hospital by ambulance and was accompanied by an ED staff nurse (RN). Upon returning to the hospital, the RN documented that during the transfer, the patient began having blood show with contractions every 3 minutes lasting 30 seconds. The baby was delivered during transport at 9:24 AM, and they arrived at the receiving hospital at 9:28 AM.

The investigator found no physician certification indicating that the physician explained the specific risks and benefits of the transfer with the patient and the patient consented to the transfer.

3. On 10/18/23 at 1:25 PM, an interview with the ED Assistant Nurse Manager (Staff #1) showed that the hospital did not have a Labor and Delivery unit, and it is common for the ED providers to transfer patients in labor to another hospital if they are stable and not at risk for imminent delivery. Staff #1 stated that when a transfer occurs, the physician is expected to complete an EMTALA Transfer Form. Staff #1 confirmed that Patient #4's medical record did not contain a completed EMTALA Transfer Form.
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