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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

FINDINGS

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

Tag C240 - Posting of Signs - Based on observation and interview, the facility failed to have a posting clearly describing patients' rights under section 1867 of the Act and the participation of the facility in the Medicaid program under a State plan approved under Title XIX, at all places likely to be seen by individuals entering the facility seeking emergency medical treatment.

Tag C2406 - Medical Screening Examination (MSE) - Based on interviews and document review the facility failed to determine and document who was qualified to perform an initial medical screening examinations and receive approval by the governing body of the hospital. This failure resulted in 20 of 20 patients who presented to the emergency department, to receive an MSE by an individual(s) who had not been determined by the facility as qualified to perform MSE's (Patient #1 - #20).

Tag C2409 - Appropriate Transfer - Based on interviews and record review the facility failed to ensure 2 of 11 patients, requiring a higher or specialized level of care, were transferred appropriately pursuant to EMTALA requirements (Patient #7 and #12).

Based on observation and interview, the facility failed to have posted, at all places likely to be seen by individuals entering the facility seeking emergency medical treatment, a posting clearly describing patients' rights under section 1867 of the Act and the participation of the facility in the Medicaid program under a State plan approved under Title XIX.

Findings include:

1. The facility failed to post notification of patient rights, under EMTALA, in all places that individuals seeking emergency medical treatment might note when entering the facility.

a. On 05/14/18 at 1:10 p.m., a tour of the facility was conducted with the chief nursing officer (CNO #3). Observations of the main entrance included a welcome sign with visiting hours. No posting was noted which described patients' rights under EMTALA.

Further touring of the hospital revealed an ambulance bay on the West side of the building. CNO #3 stated the entrance was used to bring patients in and out of the hospital by ambulance as well as patients who could present to this entrance seeking emergency services. Observation of the door and surrounding area at the hospital's ambulance bay did not contain any signage describing patients' rights under EMTALA.

The hospital's waiting room was observed. No signage describing patients' rights under EMTALA were noted.

Observation of the facility's Emergency Department (ED) was conducted. A posting was noted on the ED entrance door which described patient rights under EMTALA and included the facility participated in Medicare and Medicaid.

b. On 05/16/18 at 4:44 p.m., an interview was conducted with CNO # 3 who stated patient notification of their rights under EMTALA was important; patients had the right to know they could not be denied care even if they lacked insurance or the ability to pay. She also added that adhering to EMTALA was the law and the right thing to do.

The CNO confirmed three entrances into the facility, housing the ED, and only one entrance contained an EMTALA posting notifying patients of their rights. CNO #3 confirmed it would be possible for individuals entering the main entrance to the facility and the ambulance bay seeking emergency medical treatment to not see the EMTALA posting.

Based on interviews and document review the facility failed to determine and document who was qualified to perform an initial medical screening examinations and receive approval by the governing body of the hospital. This failure resulted in 20 of 20 patients who presented to the emergency department, to receive an MSE by an individual(s) who had not been determined by the facility as qualified to perform MSE's (Patient #1 - #20).

Findings include:

References:

Medical staff bylaws from 8/26/08 state basic qualifications for membership on the medical staff are a practioner must demonstrate compliance with all the basic qualifications in order to have an application for medical staff membership accepted for review. The practioner must: qualify under Colorado law to practice with an out-of-state license or be licensed as follows: Physician must be licensed to practice medicine by the Colorado State Board of Medicine; Dentist must be licensed by the Colorado State Board of Dentistry; Certified Registered Nurse Anesthetist; Nurse practioner by the Colorado Board of Nursing, Physician Assistants by the Colorado State Board of Medicine, podiatrist must be licensed to practice podiatry by the Colorado State Board of Podiatry, Clinical Psychologists eligible for Medical staff membership must be licensed to practice by the appropriate Colorado State licensing authority.

1. The facility failed to identify who was a designated qualified medical professional (QMP) within the facility, document those individual(s) and then receive approval by the governing body.

a. Patient #1 presented to the emergency department on 11/7/17 at 5:28 p.m. with a complaint of abdominal pain. At 5:41 p.m., the patient was seen by Physician #9 and received an MSE.

Patient #2 presented to the emergency department on 12/9/17 at 10:15 a.m. with a complaint of back pain. At 10:35 a.m., the patient was seen by Chief Medical Officer (CMO #6) and received an MSE.

Patient #3 presented to the emergency department on 2/28/18 at 3:00 p.m. for left sided numbness. The patient was seen by Physician #9 at 3:28 p.m. and received an MSE.

Similar findings were found in medical record review for Patient's #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and #20.

b. On 5/15/18 at 4:00 p.m. an interview was conducted with the chief executive officer (CEO #7). CEO #7 stated the medical staff bylaws indicated who the facility designated as a qualified medical professional. CEO #7 reviewed the facility medical staff by laws, dated August 26, 2008, and indicated a section titled basic qualifications which stated a practitioner must demonstrate compliance with all the basic qualification in order to have an application for medical staff membership accepted for review. Listed where physicians, dentists, certified registered nurse anesthetist, physician assistants, podiatrists and clinical psychologists.

On review of the medical staff bylaws there was no documentation Physician #9 and CMO #6 were designated QMPs to perform an MSE. Further review of the entire bylaws revealed no documentation of any individual(s) who the facility had designated as a QMP to perform an initial MSE and received approved by the governing body.

c. A review of the facility medical staff meeting minutes from 5/1/17 to 4/17/18 also revealed no documentation of whom the facility had designated as a QMP to perform an MSE at the facility.

d. On 5/21/18 at 3:05 p.m., an interview was conducted with Physician Assistant (PA) #8, who was on call for the emergency department. PA #8 reviewed the medical staff bylaws and facility policy, emergency room standards with CNO #3 and CEO #7 and confirmed there was no documentation which identified who the facility had designated as a QMP to do an initial MSE.

Based on interviews and record review the facility failed to ensure patients requiring a higher or specialized level of care were transferred appropriately pursuant to EMTALA (Emergency Medical Treatment and Labor Act) in 2 of 11 medical records reviewed in which patients where transferred out of the facility (Patient #7 and #12).

Findings include:

Facility policy:

The policy, Emergency Department Transfer of Patients read, documentation of patient stabilization had been prepared by a physician or qualified medical person in consultation with a physician. The policy also read, the transferring hospital should document its communication with the receiving hospital, including the date and time of the transfer request and the name of the person accepting the transfer. The receiving facility must ensure it has available space and qualified personnel for the treatment of the individual, and has agreed to accept the transfer of the individual and to provide appropriate medical treatment.

The policy, Admission to the Emergency Room read, the provider shall determine whether the patient had an emergency medical condition and if necessary, stabilize the patient and/or admit the patient or initiate a transfer under medical necessity.

The policy, Transfer of Patients: For a Patient Being Transferred to Another Health Care Facility read, the primary care provider was responsible to notify the receiving primary care provider and institution. The policy also read, the facility must copy appropriate medical records and complete patient transfer forms and orders, including a nursing summery and a care plan for the receiving facility.

1. The facility failed to ensure the receiving facility agreed to accept the patients for transfer and provide available documentation including patient consents.

a. Patient #7 presented to the emergency department on 4/8/18 at 12:37 p.m. with contractions. The patient was documented to be 40 weeks and three days pregnant with her fourth child.

At 12:44 p.m. Patient #7 was examined by Physician #4 and according to emergency department provider assessment the patient was experiencing contractions two to three minutes apart with no loss of fluid or bleeding.

At 12:49 p.m. Physician #4 documented Patient #7 needed to be transferred to a different facility (Facility B) for further labor and delivery care and that delivery was not imminent at that time.

At 12:54 p.m., according to the prehospital report the patient was transported out of the facility by ambulance to Facility B. Further documentation revealed RN #11 told the emergency medical technician (EMT) to take the patient prior to all paperwork being completed and she would have paperwork completed upon the EMT's return to the facility.

b. On 5/15/18 at 12:46 p.m. an interview was conducted with Physician #4 who had cared for Patient #7 on 4/8/18. Physician #4 stated the appropriate process for transferring a patient out of the facility included calling the receiving facility to confirm they had available beds, obtaining acceptance of the patient by a physician, giving report and filling out the proper paperwork to transport the patient.

Physician #4 stated after he examined Patient #7, he determined the patient needed to be transferred to a facility with appropriate obstetrics care and ordered the transport team to take the patient to a different facility. Physician #4 stated, the emergency transport service crew were at the patient's bedside, ready to take the patient at that time.

Physician #4 stated he did not call the receiving facility until approximately 20 minutes after the patient left and no paperwork was filled out or completed prior to transfer.

c. On 5/15/18 at 3:59 p.m. an interview was conducted with Registered Nurse #11 who cared for Patient # 7 on 4/8/18. RN #11 stated she called report to Facility B and spoke with a registered nurse in the emergency department and the labor and delivery department after Patient #7 left the facility.

RN #11 stated paperwork sent with the patient typically included the consent, any nursing documentation, vital signs and any testing completed (lab and radiology). RN #11 stated it was important to send as much information to the receiving facility so they could get the full picture of what was occurring with the patient.

RN #11 stated Physician #4 did not fill out paperwork and sign the consent for transfer until 4:30 p.m. on 4/8/18. This was 4 hours after the patient left the facility. RN #11 was unsure what paperwork had been sent with the patient and was unsure if any paperwork had been faxed by the unit clerk after it had been completed by Physician #4.

d. Similar findings were found in Patient #12's medical record.

On review of Patient #12's medical record, the patient presented to the emergency department on 11/21/17 at 10:50 a.m. Patient #12 was triaged with a primary and secondary assessment were completed at 10:56 a.m. by Registered Nurse (RN) #1. RN #1 documented Patient #12's chief complaint as suicidal with a specific plan.

At 11:14 a.m., the physician documented, on the ED Provider Assessment, that Patient #12 was brought in by ambulance with a history of bipolar, schizophrenia, anxiety, depression, post traumatic stress disorder and a recent admission to a psychiatric facility for suicidal ideation's and with worsening suicidal ideation's. The patient was seen at a clinic yesterday, 11/20/17, and was noted to "currently struggle with suicidal ideation."

At 11:41 a.m., RN #1 documented under the nursing assessment notes, Patient #12 was suicidal with a plan to overdose on her medications and complained of increased depression, anxiety and sadness.

At 1:10 p.m., on the vitals signs flow sheet, it was documented Patient #12 took pills approximately 10-15 minutes ago. Review of the Emergency Nursing Record revealed RN #1 documented the patient came up to the nurses station and said she took approximately 60 pills about 15 minutes ago.

At 2:35 p.m., a crisis evaluation was conducted. In the crisis evaluation, the crisis clinician documented Patient #12 was in need of stabilization inpatient treatment at a involuntary facility.

At 6:42 p.m., RN # 1 documented the patient was being transferred under the care of the receiving facility physician and report to the RN at the receiving facility had been completed. RN #1 further documented all documents were ready for transport.

Review of Patient #12's record revealed no documentation that the physician caring for Patient #12 communicated with the receiving hospital, including the date and time of the transfer request and the name of the person accepting the transfer. This was in contrast to facility policy.

On 5/15/18 at 1:31 p.m., an interview was conducted with the Chief Medical Officer (CMO) #6. CMO #6 stated the facility policy was to call the receiving facility to ensure the receiving facility had the capability and capacity to care for the patient who was needing to be transferred. The physician then spoke to the receiving physician who accepted the patient called a "doc to doc." This was all required prior to the patient being transported. CMO #6 stated it was important for the doc to doc communication to be completed to ensure a safe handoff of patient care because the most dangerous part of transporting patients was when the patient was outside the facility and have access to less resources. CMO #6 stated receiving acceptance of a patient and then providing a doc to doc allows for the receiving team to prepare for the patient and identify if any changes in the patient's condition had occurred while in transient.

CMO #6 on review of Patient #12's medical record confirmed there was no documentation on when the doc to doc had occurred and no documentation of what paperwork had been sent with the patient prior to being transported. CMO #6 stated the physician consent for transfer should always be completed and sent with the patient prior to being transported.