HospitalInspections.org

Based on staff interview, observations, and document review, it was determined the hospital failed to failed to ensure transfers were carried out appropriately (refer to A2409).

42929

Based on observations, interviews, and document review, the facility failed to post conspicuously a sign specifying the rights of individuals with respect to the examination and treatment of emergency medical conditions and women in labor act at the emergency medical services (EMS) entrance and the entrance to the emergency department waiting room from the hospital.

Findings:
During a tour of the emergency department on 01/16/2024 at 4:07 p.m. with Staff Member (SM) 6 and SM 2, the surveyor was brought into the facility's emergency department through a door connected to the hospital. SM 2 stated that patients could present to the emergency department through this door. The surveyor observed there was no Emergency Medical Treatment and Labor Act (EMTALA) signage visible at this location. The surveyor observed EMTALA signage on the wall inside the doors of the main emergency department entrance that is accessed from the street. There was no other EMTALA signage observed within the waiting room.

The surveyor observed that there was no EMTALA signage visible at the EMS entrance to the emergency department. SM 2 stated that the facility is constructing another building that will allow them to expand their emergency department, and that construction is occurring outside of the EMS entrance, but that entrance is still being used. When the surveyor asked SM 2 about the signage, SM 2 confirmed that it wasn't visible and that it must have been moved or covered up due to the construction.

The provided facility's policy titled "Transfer: EMTALA" effective date 05-2021 did not address EMTALA signage.

The above concerns were reviewed with the staff at the exit conference on 01/18/2023.

Based on staff interview and document review it was determined hospital staff failed to maintain an accurate central log on each individual who came to the emergency department and whether he or she refused treatment, was refused treatment, was transferred, admitted and treated, stabilized and transferred, or discharged. Specifically, the hospital's log contained inaccurate information regarding transfers and did not specify whether or not the patient was transferred or stabilized and transferred in 89 out of 7,344 patients entered into the December 2023 log and failed to ensure documentation of any discharge disposition in 66 out of 7,344 patients in December 2023's central log.

Findings:

Twenty (20) medical records were reviewed between 01/16/24 and 01/18/24. Patient #11 was listed on the hospital's central log as "transferred" on 12/29/23. Upon review of the patient's record, the patient was not transferred, but admitted to the hospital's rehabilitation unit. During record review, the surveyor asked staff member #5 why the patient was listed as transferred on the central log, but had not been transferred. Staff member #5 stated that the patient was "transferred" to the hospital's rehabilitation unit. Staff member #5 confirmed the rehabilitation unit was within the same certified hospital and the patient was not transferred to another facility. The surveyor asked staff member #5 how one can determine from the central log whether a patient was transferred to another facility or transferred to another unit within the hospital. Staff member #5 stated there was no way to determine which patients were transferred to another facility from the emergency department's central log.

The hospital's policy related to maintaining a central log of emergency department patients was requested. Staff member #11 confirmed the hospital had no policy related to a central log. The central log was reviewed with staff member #11 on 01/18/24 who confirmed they were unable to determine from the central log which patients were transferred to another hospital. Staff member #11 also acknowledged the log did not contain documentation of whether or not patients were stabilized or transferred and that 66 patients on December's log contained no disposition.

The above noted findings were reviewed with the staff at the exit conference on 01/18/2023.

Based on staff interview and document review, it was determined the hospital failed to ensure transfers were carried out appropriately in two (2) of five (5) applicable medical records reviewed. Medical record #'s 3 and 13. Specifically, the patient's medical records failed to contain documentation of a physician certification that the benefits outweighed the risks of transfer, failed to document the name of the physician who accepted the transfer at the receiving hospital, failed to ensure all medical records were sent to the receiving hospital, and failed to ensure the transfer was performed through qualified personnel and transportation equipment.

Findings:

The medical record for patient #13 contained documentation that the patient presented to the Emergency Department (ED) on 12/02/23 with recent bladder removal surgery on 11/19/23. The patient noted bleeding, pain, and swelling to the incision cite and came to the ED. The physician note from the ED reads in part: "On arrival here (they) was hemodynamically stable but tachycardic pale appearing with tenderness along (their) incision site and concern for potential abscess versus hematoma/intraabdominal bleeding. Patient was anemic more than (their) baseline with initial CBC of 7.5 and a Chem-8 of 6.5. Type and screen ordered and two units of RBCs (red blood cells) were ordered. Patient had leukocytosis and persistent tachycardia with clinical examination consistent with concern of infection. Patient was treated empirically with broad-spectrum antibiotics metronidazole and ceftriaxone. CT imaging of the abdomen demonstrated development of intra-abdominal abscesses along the abdominal wall as well as fluid collections along the incision and potential infectious etiologies in the lung bases. [Name of hospital] was contacted as this patient was a recent postoperative case...and they would like the patient transferred for definitive management."

The medical record failed to contain evidence of a signed physician certification including the risk and benefits of the transfer, failed to contain evidence of the name of the physician accepting the patient at the receiving facility, failed to contain evidence that the transferring hospital confirmed the receiving hospital had space and qualified personnel prior to transferring the patient, failed to contain evidence any records were sent to the receiving hospital prior to transfer and failed to contain evidence of documentation of the type of transportation that was required or utilize to effectuate the transfer.

The last documentation in the medical record was at 9:54 AM on 12/02/23 of a pain assessment completed by the nurse. The documentation contained no information about when the patient left the facility or what type of transportation the patient took to the receiving hospital. The record contained no documentation that the patient consented to the transfer or that the risks and benefits of the transfer were explained to them. Staff member #5 confirmed during record review that this information should have been documented on the transfer form and that the medical record failed to contain such form.

The medical record for patient #3 contained documentation that the patient was transferred to an inpatient psychiatric hospital on 12/14/23. The record contained a document, "Transfer/EMTALA Form." The Transfer/EMTALA form contained a field for the physician to indicate who initiated the transfer. This field was left blank. The form contained a field to indicate if the patient was stable or unstable at the time of transfer. This field was also left blank. The form contained an area to document what documents were sent to the receiving facility. This field was also left blank. The medical record contained no documentation of whether or not the patient was stable at the time of discharge or what documents if any were sent to the receiving hospital.

On 01/16/2024 at 9:22 AM, the surveyor reviewed patient #3's ED "Transfer/EMTALA Form" with staff member #5. Staff member #5 stated that nurses complete the top section of the form to include the "RN Signature" and "Report given to at the receiving facility." Staff member #5 stated that the next section of the form on page one (1) to include if the patient is "stable" or "unstable" should be completed by the provider. Staff member #5 stated that the facility is currently working on educating staff on ensuring the "Checklist of Documents" section at the bottom is being completed. Staff member #5 confirmed the medical record for patient #3 did not contain documentation of whether or not the patient was stable at time of discharge and what documents if any were sent to the receiving hospital.

The facility's policy titled, Transfer: EMTALA was reviewed and reads in part: "C. Psychiatric Patients: Patients who may be a danger to themselves or others due to mental or emotional illness or disturbance shall be noted as unstable on the Certificate of Transfer. These patients shall only be transported by ambulance, or law enforcement, with appropriate measures taken for the patient's security, so that no deterioration in condition is likely to result from the transfer, including harm to the patient or others"... "Patient Transfers to Other Hospitals:
C. Documentation: The condition of each patient transferred shall be documented in the medical record by the physician responsible for providing the medical examination and stabilizing treatment.
1. The Transfer/EMTALA form will be completed, including a summary of the risks and benefits of the proposed transfer.
2. The patient's consent or refusal must be documented in the medical record and on the Certificate of Transfer. "...
"E. Medical Records: When a patient is transferred, the Emergency Department or other department transferring the patient will send with the patient appropriate medical records regarding its treatment of the individual including, but not limited to, observation of signs or symptoms, preliminary diagnosis, treatment provided, results of any tests, informed written consent and certificate of transfer, and the name and address of any on-call physician who has refused or failed to appear within a reasonable period of time to provide stabilizing treatment. Records not available at the time of transfer will be sent to the receiving facility as soon as possible.
F. Report: A report should be called to the receiving facility by the primary nurse for the patient including patient history, condition, and treatments provided at the sending facility to assist the receiving facility in preparing for the patient's arrival.
G. Method of Transportation: Appropriate level of transportation will be determined by the Emergency Department, transfer center, or attending physician and appropriate medical transport and qualified personnel will be contacted and obtained by the Emergency Department staff for patients in the Emergency Department and Transfer Center staff for all other patients."