HospitalInspections.org

Based on interviews and document review, the facility failed to comply with the Medicare provider agreement, as defined in §489.24, related to Emergency Medical Treatment and Labor Act (EMTALA) requirements.

Findings:

1. The facility failed to meet the following requirements under the EMTALA regulation:

Tag A2402 - Posting of Signs - The facility failed to post signs in all entrances and waiting rooms, a sign specifying the rights of individuals seeking examination and treatment for emergency medical conditions and women in labor. Specifically there was no EMTALA signage at the main entrance to the hospital or in the waiting area outside the locked labor and delivery unit where patients presented for labor and delivery.

Tag A2405 - Emergency Room Log - The facility failed to ensure that a central log was accurately maintained to include all patients seeking emergency care at the facility and to reflect the correct disposition of patients seen in the Emergency Department (ED). Specifically, one patient who presented to the ED on 6/17/18, with a complaint of shortness of breath was not entered on the central log (Patient A) and the disposition listed on the log was incorrect for 2 of 20 patients reviewed (Patients #4 and #12).

Tag A2406 - Medical Screening Exam - The facility failed to ensure a Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation was provided by qualified medical personnel (QMP) in 2 of 2 records reviewed for patients who presented to the facility and were directed to the co-located emergency department of a separately certified hospital (Patient #12 and Patient A). This failure resulted in the delay of care for a patient experiencing an emergency medical condition.

Based on observation and interviews the facility failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) signage was posted at relevant locations in the facility.

POLICY

The Emergency Medical Treatment and Active Labor Act (EMTALA) policy stated the hospital will post conspicuously, in the dedicated emergency departments and labor and delivery and psychiatric units, as well as all defined areas in which patients routinely present for treatment of emergency medical conditions and wait prior to examination and treatment (such as entrance, admitting areas, waiting room or treatment room), that specify rights of an individual under the law with respect to examination and treatment for emergency medical conditions and of women who are pregnant and are having contractions.

1. The facility failed to post signs, specifying the rights of individuals seeking examination and treatment for emergency medical conditions and women in labor, at entrances and waiting areas used by patients seeking emergency services and by pregnant women. Specifically, there was no EMTALA signage at the main entrance to the hospital or in the waiting area outside the locked labor and delivery unit.

a) During a tour of the hospital lobby on 7/9/18 at 1:45 p.m. with the Regulatory Manager (Manager #1), no EMTALA signs were posted at the main entrance to the hospital, in the lobby or at the patient registration area in the lobby.

b) During the tour, a hospital volunteer (Volunteer #2) was sitting at the information desk in the main lobby. Volunteer #2 stated patients looking for the emergency department frequently stopped at the information desk. Volunteer #2 stated she would give directions to the emergency department and escort the patient to the department if needed.

c) Patient Liaison (Liaison #3) joined the lobby tour. Liaison #3 stated that an order had been placed for additional EMTALA signs to be posted. When asked if the order included signs for posting at the hospital entrance, Liaison #3 responded no.

d) A tour of the floor of the hospital housing the labor and delivery unit took place on 7/10/18 at 9:30 a.m., with the Manager of Women Services (Manager #4). The tour was initiated in the waiting area outside the labor and delivery unit. Patient access doors to the unit were locked and patients coming to the unit to be evaluated for labor and contractions were required to use an intercom system to indicate their presence in the waiting area and have the doors released allowing them to enter the unit. No EMTALA signs were posted in the waiting area for the labor and delivery unit.

Based on interviews and document review, the facility failed to ensure a central log was accurately maintained to include all patients seeking emergency care at the facility and to reflect the correct disposition of patients seen in the Emergency Department (ED). Specifically, one patient who presented to the ED with a complaint of shortness of breath was not entered on the central log (Patient A) and the information listed on the log was incorrect for 2 of 20 patients reviewed (Patients #4 and #12).

POLICY

According to the Emergency Medical Treatment and Active Labor Act (EMTALA) policy, a central log must list each individual seeking or in need of emergency services who comes to the hospital. The log must include an indication whether the individual did not consent to treatment or transfer, or was transferred, admitted and treated, stabilized and transferred, or discharged.

A central log must include the name of the individual who comes to the hospital and makes it clear (or if it is unclear) that the medical condition is not an emergency nature, and a medical screening examination is performed to determine that the individual does not have an emergency medical condition.

1. The facility failed to maintain a complete and accurate central log of patients who presented to the facility.

a) Review of a paper EMTALA LOG maintained by patient registration personnel at the entrance to the emergency department (ED) indicated that on 6/17/18 at approximately 4:30 a.m. a father carrying a young male came to the ED. The reason listed for the visit was shortness of breath (SOB). The documented reason for leaving the ED noted the father said he was looking for another hospital. There was no additional documentation on the log.

Review of the electronic central EMTALA Log for 6/17/18 revealed no entry for Patient A.

During an interview with Patient Access Manager (Manager) #5 on 7/10/18 at 3:30 p.m., Manager #5 stated she had created the log for the registrars to utilize when someone walked in and decided they wanted to leave before an electronic record was created. Manager #5 stated she instructed registrars to fill out the date, time of arrival, description of patient, personal identifiers such as date of birth, the reason for visit and why the patient decided to leave. When asked how the registrar identified the reason for the visit, Manager #5 stated that patients would walk in and tell you what they were there for and the registrar wrote down what the patient told them for the reason for the visit.

b) Review of the separate paper EMTALA LOG maintained by patient registration personnel at the entrance to the ED indicated that on 3/5/18 at 7:12 p.m., Patient #12 was brought to the ED. The reason listed for the visit stated "psych[iatric] eval[uation]." The reason listed for leaving stated registered nurse (RN) "advised" the patient to go to the co-located ED of a separately certified hospital. The time listed for Patient #12 leaving the facility was 7:12 p.m.

Review of the electronic central EMTALA Log for 3/5/18 identified 7:09 p.m. as the arrival time and 7:12 p.m. as the departure time for Patient #12. The log indicated "psych eval" as the chief complaint and the ED disposition portion of the log was blank. The medical record for Patient #12 indicated the patient left without being seen as the discharge information. There was no nursing documentation in the medical record indicating that the patient was advised to go to another acute care hospital.

c) Review of the electronic central EMTALA Log for 1/10/18 revealed Patient #4 arrived at the hospital by ambulance on 1/10/18 at 2:30 a.m. The log indicated that Patient #4 was a deceased male that was transferred to another acute care hospital. Review of the medical record revealed that Patient #4 was transferred to another acute care hospital on 1/10/18 at 5:55 a.m. Patient #4 expired at the other acute care hospital on 1/25/18, 15 days after the transfer.

During an interview with Director of Emergency Services (Director) #5, on 7/11/18 at 2:50 p.m., she stated there was a flaw in the electronic medical record software system used and that it would need to be fixed. She indicated that since Patient #4 was transferred to a sister facility (a separately certified hospital under the same corporation) when the death occurred the information was updated on the EMTALA Log. Director #5 stated "if I had the log printed on 1/15/18, I'm sure it wouldn't show the patient as being deceased."

Based on interviews and document review, the facility failed to ensure a Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation was provided by qualified medical personnel (QMP) in 2 of 2 records reviewed for patients who presented to the facility and were directed to the co-located emergency department of a separately certified hospital (Patient #12 and Patient A). This failure resulted in the delay of care for a patient experiencing an emergency medical condition.

Findings include:

Facility policy:

According to Emergency Medical Treatment & Active Labor Act (EMTALA), the hospital will provide a medical screen examination (MSE) to determine whether an emergency medical condition exists for an individual who comes to the dedicated emergency department, requesting examination or treatment for a medical condition or has such a request made on his/her behalf, or if based on a prudent person's observation the individual's appearance or behavior, the individual needs an examination or treatment for a medical condition.

1. The facility failed to ensure all patients who came to the emergency department seeking emergency medical treatment received a medical screening examination (MSE) to determine if an emergency medical condition existed.

a) Review of a paper EMTALA LOG, maintained by patient registration personnel at the entrance to the emergency department (ED), indicated that on 6/17/18 at approximately 4:30 a.m. a father carrying a young male came to the ED. The reason listed for the visit was shortness of breath (SOB). The reason documented for leaving the ED was the father said he was looking for another hospital.

Review of the Hospitalist History and Physical, dated 6/17/18, showed Patient A was brought to the facility's ED as he had a worsening of his breathing pattern with apnea (cessation of breathing, especially during sleep) and "gurgling sounds." He was "deferred" from the facility's ED to a co-located hospital's pediatric ED "as when he was asked is he a child by admitting/security personnel, he (father) responded yes and as such was advised to take him to [the pediatric ED co-located by the facility's ED]." According to the medical record Patient A was 27 years old and was subsequently admitted to the facility after being transferred from the co-located pediatric ED.

Subsequent to the 6/17/18 event, the facility interviewed the security officer who encountered the patient when he presented to the ED. Review of an undated, typewritten report from the security officer noted, on the morning of 6/17/18 the security officer "encountered a male and what seemed to be his child." The male walked in to the ED and "looked confused and unsure of where to go so I asked him if he was looking for [a separately certified co-located ED]. He responded yes and I directed him towards the [co-located ED] entrance."

During an interview, on 7/10/18 at 11:16 a.m., Director of Emergency Services (Director) #6 stated at the time Patient A presented to the ED the security officer was the first person the patient would encounter. Due to current construction at the entrances of the co-located EDs a security officer was the first person encountered when patients entered. According to Director #6 there was a lot of miscommunication on the parts of both separately certified hospitals regarding Patient A, on 6/17/18. Director #6 stated after the incident with Patient A the facility had stationed a clinical person at the entrance to the ED.

b) Review of the paper EMTALA LOG revealed that on 3/5/18 at 7:12 p.m., Patient #12 was brought to the ED for a psychiatric evaluation. Under the section noted Reason For Leaving, it was documented the registered nurse (RN) "advised" the patient to go to the co-located ED of a separately certified hospital. The time listed for Patient #12 leaving the facility was 7:12 p.m.

However, conflicting documentation in Patient #12's medical record noted the patient left without being seen. There was no documentation in the medical record the pediatric patient received a MSE prior to being "advised" to go to the separately certified co-located ED.