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Based on record review of the Central Log for Emergency Patients, review of Emergency Medical Services report documentation, staff and provider interviews and review of the facility EMTALA policies and procedures, the facility failed to ensure staff followed their Emergency Medical Treatment and Labor Act (EMTALA) policies and procedures related to the documentation and transfer of 1 (Patient 11) of 8 sampled patients who were transferred to a higher level of care for specialized treatment. This failure has the potential to affect all Emergency Department (ED) patients. Failure to include patients in the Central Log makes the facility unable to track the care provided to patients who come to the ED. Failure to complete transfer documentation and send patient records to the receiving facility has the potential for harm related to a delay or error in treatment of an Emergency Medical Condition. The total sample included 21 ED patient records.See also C 2405 and C2409.
Findings are:

A. Record review of facility policy titled "EMTALA, Medical Screening Exams and Transfers" last revised 3/2016 documents policies and procedures staff are to follow to be in compliance with EMTALA Regulations. Under the section titled "Purpose" the policy defines the Dedicated Emergency Department as "the hospital nurses station, ambulance ramp and entry way and all emergency Department Rooms north of that nurses station." Under the section titled "ED Log" states "All individuals presenting in the DED, and for whom examination or treatment is requested shall be logged in and a medical record shall be created."
Under the section titled "Restricting Transfer until Individual is Stabilized" the policy states that "The medical provider signs a certification based on information available at the time of transfer, that the medical benefits of care reasonably expected at the receiving facility outweigh the increased risk to the individual."
Under the section title "Appropriate Transfer" the policy states "The medical provider will contact the receiving medical provider and the hospital will contact the receiving facility for acceptance of the patient." The policy notes that the receiving hospital must agree to the transfer and to provide the appropriate care. The "advanced acceptance of the receiving medical provider and the receiving hospital will be documented on the Certificate of Transfer form." The hospital must send to the receiving facility "all medical records related to the emergency condition for which the individual presented. Include records related to the individual's emergency condition, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of any tests and the informed written consent or certification." The hospital staff person "will call a patient report to the destination hospital staff person and document on the patient transfer order. This report must be done before the patient leaves this facility."

B. Record review of the Central Log on 5/29/18 found Patient 11 who was brought to the hospital by EMS personnel and transferred to Hospital B for specialized care on 5/16/18 was not entered into the Central Log as required by facility policy and EMTALA requirements.

C. Review of the EMS documentation for Patient 11 on 5/29/18 found the patient was taken from home to the hospital with a possible overdose requiring intubation to maintain an open airway on 5/16/18. The EMS documentation notes they arrived at the hospital at 8:21 PM and on arrival Nurse Practitioner (NP) A, the ED provider, met the ambulance outside. The EMS record notes that the NP confirmed the endotracheal tube placement, performed a patient assessment and notified them that the helicopter service was enroute and would meet them at the airport for transport to Hospital B.
Interview on 5/30/18 at 3:40 PM with NP A on 5/30/18 at 3:40 PM revealed NP A went into the ambulance while outside the ED to assess the patient. The patient was intubated by Paramedic B while in the ambulance outside the ED. NP A stated that Hospital B was contacted by Registered Nurse D for transfer acceptance. NP A also asked RN D to arrange for helicopter transport to Hospital B. NP A recalled speaking with ED Medical Doctor (MD) F, the receiving hospital ED MD informing him of the transfer needed for possible overdose and that the patient was intubated due to low Oxygen saturations and low Glasgow Coma Score (GCS). [GCS is a scoring system for level of consciousness. A low score means the patient may be unresponsive and unable to maintain their airway.] NP A stated during the interview that the patient was accepted by Hospital B and that they understood the patient was coming by helicopter and was intubated. NP A recalled receiving a call from Hospital B Intensive Care Nurse the next day on 5/17/18 wanting any records they had on the patient. NP A stated that there were "no ED notes made, that was my fault." NP A stated "I did not think to enter any information on the patient as he was not registered in the Emergency Room. We provided care but none of us made a medical record for the patient or filled out transfer papers."
Interview with RN D on 5/30/18 at 4:40 PM confirmed RN D did call Hospital B's transfer center. The NP got the Hospital BER MD to accept the patient. RN D stated that the helicopter service will not come unless the transfer was accepted. RN D confirmed staff "did not fill out EMTALA papers and Electronic [central] log because the patient was not see in the ED."
Request on 5/29/18 for of all documentation of the care provided to Patient 11 found only the EMS report provided by the paramedic. There was no medical record of the patients care provided by the hospital or any transfer documentation of advanced acceptance, risk /benefit, physician certification, treatment provided, vital signs at time of transfer or any records sent or faxed to the receiving facility about the patient.

Based on record review of the Central Log for emergency patients, review of Emergency Medical Services (EMS) report documentation, staff and provider interviews and review of the facility EMTALA policies and procedures, the facility failed to ensure 1 (Patient 11) of 21 sampled emergency patients was entered into the Central Log as required. This failure has the potential to affect all Emergency Department (ED) patients. Failure to include patients in the Central Log makes the facility unable to track the care provided to patients who come to the ED.
Findings are:

A. Record review of facility policy titled "EMTALA, Medical Screening Exams and Transfers" last revised 3/2016 documents policies and procedures staff are to follow to be in compliance with EMTALA Regulations. Under the section titled "Purpose" the policy defines the Dedicated Emergency Department as "the hospital nurses station, ambulance ramp and entry way and all emergency Department Rooms north of that nurses station." Under the section titled "ED Log" states "All individuals presenting in the DED [Dedicated Emergency Department], and for whom examination or treatment is requested shall be logged in and a medical record shall be created."


B. Record review of the Central Log on 5/29/18 found Patient 11 who was brought to the hospital by EMS personnel and transferred to Hospital B for specialized care on 5/16/18 was not entered into the Central Log as required by facility policy and EMTALA requirements.

C. Review of the EMS documentation for Patient 11 on 5/29/18 found the patient was taken from home to the hospital with a possible overdose requiring intubation to maintain an open airway on 5/16/18. The EMS documentation notes they arrived at the hospital at 8:21 PM and on arrival Nurse Practitioner (NP) A, the ED provider met the ambulance outside. The EMS record notes that the NP confirmed the endotracheal tube placement, performed a patient assessment and notified them that the helicopter service was enroute and would meet them at the airport for transport to Hospital B.
Interview on 5/30/18 at 3:40 PM with NP A revealed NP A went into the ambulance while outside the ED to assess the patient.
Interview with Registered Nurse (RN) D on 5/30/18 at 4:40 PM confirmed staff did not fill out Electronic [central] log because the patient was not see in the ED. The patient was treated in the ambulance on hospital property outside the ED.

Based on record review of the Central Log for Emergency Patients, review of Emergency Medical Services report documentation, staff and provider interviews and review of the facility EMTALA policies and procedures, the facility failed to ensure policies and procedures were followed to ensure an appropriate transfer for 1 (Patient 11) of 8 sampled patients who were transferred to a higher level of care for specialized treatment. Patient 11 was sent to Hospital B with an Emergency Medical Condition requiring further specialized care for stabilization at Hospital B. The documentation of patient care, assessment, physician certification, advanced acceptance, medications and treatment provided was not provided to Hospital B. This failure has the potential to affect all Emergency Department (ED) patients. Failure to complete transfer documentation and send patient records to the receiving facility has the potential for harm related to a delay or error in treatment of an Emergency Medical Condition (EMC). The total sample size included 21 emergency patient records.
Findings are:

A. Record review of facility policy titled "EMTALA, Medical Screening Exams and Transfers" last revised 3/2016 documents policies and procedures staff are to follow to be in compliance with EMTALA Regulations. Under the section titled "Purpose" the policy defines the Dedicated Emergency Department as "the hospital nurses station, ambulance ramp and entry way and all emergency Department Rooms north of that nurses station."
Under the section titled "Restricting Transfer until Individual is Stabilized" the policy states that "The medical provider signs a certification based on information available at the time of transfer, that the medical benefits of care reasonably expected at the receiving facility outweigh the increased risk to the individual."
Under the section title "Appropriate Transfer" states "The medical provider will contact the receiving medical provider and the hospital will contact the receiving facility for acceptance of the patient." The policy notes that the receiving hospital must agree to the transfer and to provide the appropriate care. The "advanced acceptance of the receiving medical provider and the receiving hospital will bee documented on the Certificate of Transfer form." The hospital must send to the receiving facility "all medical records related to the emergency condition for which the individual presented. Include records related to the individual's emergency condition, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of any tests and the informed written consent or certification." The hospital staff person "will call a patient report to the destination hospital staff person and document on the patient transfer order. This report must be done before the patient leaves this facility."

B. Review of the EMS documentation for Patient 11 on 5/29/18 found the patient was taken from home to the hospital with a possible overdose requiring intubation to maintain an open airway on 5/16/18. The EMS documentation notes the patient was found at a residence, supine in bed with snoring respirations and an empty bottle of Serroquel, an anti psychotic medication. GCS (GCS is a scoring system for level of consciousness with 3 being unconscious and 15 awake and normal) score of 10. Blood pressure (BP 115/69, pulse high at 133, respirations 30, and Oxygen saturation of 90 % on 2 liters of home Oxygen (normal is 90-99% for a patient on Home Oxygen). An Intravenous (IV) line was started with Normal Saline at 7:35 PM . Enroute to the hospital the patient's GCS dropped to 3. EMS notes do not document time of arrival at the hospital. The notes state that on arrival Nurse Practitioner (NP) A, the ED provider, met the ambulance outside the ED. The EMS Paramedic B, who also works at the hospital when not on EMS calls, prepared the Rapid Sequence Intubation sedation medications for insertion of an endotracheal tube into the airway to ensure the patients airway was open and breaths can be delivered. The patient was intubated in the ambulance successfully by Paramedic B. The EMS record notes that Nurse Practitioner (NP) "A" confirmed the endotracheal tube placement, performed a patient assessment and notified them that the helicopter service was enroute and would meet them at the airport for transport to Hospital B.

C. Interview on 5/30/18 at 3:40 PM with the hospital ED provider, NP A , revealed NP A went into the ambulance while outside the ED to assess the patient. The NP recalled assessing the patient and noted Patient 11 had a GCS of 3-4 [ A low score of less than 8 means the patient may be unresponsive and unable to maintain their airway] and required intubation. She recalled discussing the need for intubation with Paramedic B. The patient was intubated by Paramedic B while in the ambulance outside the ED. A second IV line was started by the ED RN as the one the EMS put in had infiltrated (moved out of the vein). IV fluid bolus of 500 milliliters was given then slowed. NP A recalled the heart was in normal sinus rhythm. BP was good and the Oxygen saturation was staying up. NP A stated that Hospital B was contacted by Registered Nurse D for transfer acceptance. NP A also asked RN D to arrange for helicopter transport to Hospital B. NP A recalled speaking with ED Medical Doctor (MD) F, the receiving hospital ED informing him of the transfer needed for possible overdose and that the patient was intubated due to low Oxygen saturations and low GCS. NP A stated during the interview that the patient was accepted by Hospital B and that they understood the patient was coming by helicopter and was intubated. NP A confirmed the patient had an EMC and they they had stabilized the patient within their capabilities while in the ambulance on hospital property. NP A recalled receiving a call from Hospital B Intensive Care Nurse the next day wanting any medical records the facility had on the patient. NP A stated that there were "no ED notes made, that was my fault." NP A stated "I did not think to enter any information on the patient as he was not registered in the Emergency Room. We provided care but none of us made a medical record for the patient or filled out transfer papers [Certificate of Transfer Form]."
Interview with RN D on 5/30/18 at 4:40 PM confirmed RN D did call Hospital B's transfer center. RN D then gave NP A the phone to speak to the ER MD from Hospital B. RN D recalled the NP got Hospital B's ER MD to accept the patient. RN D stated that the helicopter service will not come unless the transfer was accepted. RN D confirmed staff did not fill out EMTALA paperwork including the Certificate of Transfer because the patient was not see in the ED. The patient was treated outside the ED in the ambulance outside the ED on hospital property.
Interview with Paramedic B on 5/30/18 at 6:00 PM stated that on arrival at the hospital NP A and an ED RN jumped into the ambulance. Paramedic B gave the medications (sedating and paralyzing) agents to facilitate intubation and intubated the patient successfully. Placement of the Endotracheal tube was verified by NP A by listening to lung sounds, improved Oxygen saturation levels and capnography ( device that monitors carbon dioxide on inhalation and exhalation) the patient was bagged with Oxygen at 15 liters to the Endotracheal tube to maintain Oxygen levels. They left the hospital (time not documented) to meet the helicopter air transport at the airport (distance 4.6 miles). Handoff to the helicopter air crew, RN and Paramedic, was at 8:40 PM. Paramedic B recalled telling them the patients vital signs, name, phone number, drugs and time to the RN. Paramedic B wrote the information on paper but did not keep a copy. At the time of the transfer the patient had IV's, endotracheal tube airway, and a gastric tube (inserted at the airport). The patient was breathing against the Oxygen bag to tube (an indicator the intubation sedation medications were wearing off) and they gave the patient Versed 2 mg IV ( a medication to sedate the patient to provide easier ventilation). Paramedic B said the patient's Oxygen saturation was 98 % and the patient was stabilized within our capabilities. The last vital signs recorded on the EMS record are at 8:40 PM documenting BP 101/66, pulse 117, respirations 16 with bagging by staff to the Endotracheal tube.

D. Request for of all documentation of the care provided to Patient 11 found only the EMS report. There was no medical record of the patients care provided by the hospital or any transfer documentation of advanced acceptance, risk /benefit, physician certification, treatment provided, Vital signs at time of transfer or any records sent or faxed to the receiving facility about the patient. The facility required Certificate of Transfer with that information was not generated for this patient to facilitate communication between the hospital and the receiving Hospital B.

E. Review of the receiving hospital (Hospital B) medical record shows the patient arrived at 9:35 PM on 5/16/18. Review of the ED provider notes for 5/16/18 stated the patient required emergent intubation at 9:42 PM as the "prior ET [endotracheal] tube had been dislodged." The patient was discharged 5/23/18.