HospitalInspections.org

Based on observations, interviews, and record review, the facility was found not in compliance with the Emergency Medical Treatment and Labor Act (EMTALA) by failing to conspicuously post appropriate EMTALA signs, and failing to maintain an Emergency Department Patient Log, and failing to provide an appropriate transfer.

The findings are:

A. The facility failed to conspicuously post appropriate EMTALA signs. Refer to 2402.

B. The facility failed to maintain an Emergency Department Patient Log. Refer to 2405.

C. The facility failed to provide an appropriate transfer. Refer to 2409.

Based on observation, interview, and record review the facility failed to conspicuously post in the Emergency Department waiting area a sign specifying the rights of individuals under section 1867 of the Act with respect to Examination and Treatment of Emergency Medical conditions and women in labor act (EMTALA) and indicate whether the hospital participates in the Medicaid program. This deficient practice is likely to affect all patients that are accessing the Emergency Department and deprive them of their rights under EMTALA.

The findings are:

A. On 04/11/23 at 10:00 am, during an observation of the hospital entrance revealed no EMTALA signage was posted in the main lobby of the hospital.

B. On 04/11/23 at 10:05 am, during an interview with Inpatient Admissions Staff (S) 9. S9 stated "sometimes patients come into the main lobby wanting to be seen at the ED (Emergency Department). If they can wait, then I call the ED and let them know someone is in the lobby." She stated the patient waits until the tech comes out to get information and vital signs. "Sometimes patients continue to wait in the main hospital lobby for a little while."

C. On 04/11/23 at 9:00 am, during an observation of Emergency Department Internal Hall and all patient rooms had EMTALA signs that did not indicate whether the hospital participates in the Medicaid program.

D. On 04/12/23 at 10:57, during an interview with Administrator (S1). S1 confirmed EMTALA sign did not indicate whether the hospital participated in the Medicaid program, and stated "I didn't know it was supposed to be on there."

E. On 04/12/23 at 10:57, during an interview with Administrator (S)1 confirmed there was no EMTALA sign in the main lobby waiting area and stated she "will post the sign."

Based on record review and interview the facility failed to maintain a log of individuals that presented to the Hospital seeking emergency medical care and left without being seen for 1 (P [patient] 1) out of 21 (P1-P21) patients reviewed for seeking emergency medical care. The deficient practice can lead to patients not receiving necessary stabilizing care.

The findings are:

A. Record review of hospital policy titled, "Triage - Patient Assessment" undated, states under "Procedure: - Upon arrival into the Emergency Department triage/waiting area, the patient shall be checked in by Nursing Staff. - The patient shall be take into open emergency room and the Registered nurse shall evaluate the patient. . ."

B. Record review of video footage from 01/03/2023 revealed P1 entering the hospital at 4:33 AM, at 4:34 AM revealed hospital staff approaching the front door, P1 then sits in the lobby, at 5:07 AM, P1 exits the hospital. Evidence did not reveal that patient was checked in or triaged.

C. On 04/11/2023 at 9:15 AM, during an interview with Staff (S) 1, Administrator and S2, DON (Director of Nursing) it was asked during patient registration, how does staff monitor who is waiting in the lobby. It was explained by both staff members that a hospital tech will come out to the lobby and gather basic information on the patient and relay to the nurse what the patient is presenting for. Registration is done by the nurse when the patient is taken into the Emergency Department for triage. It was asked if the information the tech gathers is maintained on a central log, it was confirmed that they do not maintain a log of patients that are not registered.

Based on record review and interview the facility failed to have a process in place for patients that choose to transfer via private vehicle and ensure they understand the risks involved for 2 (P[Patient]8, P9) and failed to explain the risks of transfer to 6 (P3, P4, P6, P11, P12, and P13) out of 21 patients reviewed for seeking emergency medical care. The deficient practice could lead to unfavorable outcomes while patient is en route to accepting hospital.

The findings are:

Failed to have a process in place for patients that choose to transfer via private vehicle and ensure they understand the risks involved:

A) Record review of facility policy titled, "Transfer of patient to another facility" dated 10/21/2021 does not include information regarding a patient choosing or being recommended to take a personal vehicle to another hospital.

B) Record Review of P8's medical record revealed the following:
1) Document titled "Physician ED [Emergency Department] H&P [History and Physical]" dated 02/14/2023 2:44 AM in "A/P [Assessment/Plan]" it states "clinical Impression: Acute appendicitis [inflammation of the appendix; often requires surgery] according to CT . . . Disposition: Transfer to [name of accepting facility]"
2) Document titled, "Physician Assessment and Certification Transfer Summary" reveals that patient was accepted by the receiving hospital at 7:23 AM on 02/14/2023. The second page of this document states, "Transfer Consent I acknowledge that my medical condition has been evaluated and explained to me by the physician on duty who has recommended that I be transferred to the service of [name of accepting physician and facility]. I understand the potential benefits of such transfer, and the probable risks of not being transferred. With this knowledge and understanding, I agree and consent to be transferred." This is signed by the patient. There is no statement on this document that the patient will take their personal vehicle and understands the risks.
3) Document titled "[Facility name] ER [Emergency Room] Triage Note" dated 02/14/2023 on page 8 it is documented, "0840 [8:40 AM] informed pt [patient] no ground crew available to transport her to [name of neighboring city] and flight crews have declined transport as well. Pt informed this nurse her husband can take her to [neighboring city] via POV [privately owned vehicle]; they verbally expressed understanding of risks involved with POV transport 0914 [9:14 AM] Fentanyl [opioid pain medication] 50 mcg slow IVP [intravenous push] administered; pt tolerated well. Pt is on 2L [liter] O2 [oxygen] via nc [nasal cannula] . . . 0955 [9:55 AM] . . . Pt taken out of facility via wc [wheelchair] without insult."
4) Document titled "Cumulative Vitals/Measurements Report" reveals that on 02/14/2023 at 9:43 AM P8's vital signs showed her oxygen was 97% on 2L of oxygen via nasal cannula. There is no documentation that patient was transitioned and stable on room air nor is there documentation that patient was sent with oxygen during transport.

C) Record Review of P9's medical record revealed the following:
1) Document titled "Physician ED H&P" dated 11/03/2022 1743 [5:43 PM] in "A/P" it states "Pneumoperitoneum [abnormal gas or air in the abdominal cavity] . . . Dispo [disposition]: Transfer patient to [name of accepting hospital]. Given stability, feel transfer via POV is acceptable as air transport would be only other alternative and does not appear appropriate for patient."
2) Document titled, "Physician Assessment and Certification Transfer Summary" reveals that patient was accepted by the receiving hospital at 7:41 PM on 11/03/2022. The second page of this document states, "Transfer Consent I acknowledge that my medical condition has been evaluated and explained to me by the physician on duty who has recommended that I be transferred to the service of [name of accepting physician and facility]. I understand the potential benefits of such transfer, and the probable risks of not being transferred. With this knowledge and understanding, I agree and consent to be transferred." This is signed by the patient. There is no statement on this document that the patient will take their personal vehicle and understands the risks.
3) Document titled "[Facility name] ER Triage Note" dated 11/03/2022 on page 6 it is documented, "2313 [11:13 PM] Pt departs this facility with her daughter as her mode of transport and they are in route to [name of accepting hospital] for further care."

D) During an interview on 04/12/2023 at 1:24 PM with Staff (S)6, MD [Doctor of Medicine] it was asked if transfer via private vehicle was appropriate for a patient that has been determined to be having a medical emergency. It was explained by S6, MD that transfer via private vehicle would not be ideal but there are circumstances (for example- ground transport not available and flight unable due to weather) that they may recommend that route if the patient is unlikely to deteriorate. The alternative would be waiting for transport which could take days. It was also asked if a patient would be sent in their private vehicle with oxygen if they were requiring it, it was stated, "That would be atypical and would require a very specific circumstance."

Failed to explain the risks of transfer:

E) Record Review of facility policy titled, "Transfer of Patient to Another Facility" revised 10/21/2021 states on page 2, "Transfer papers shall be completed: -Physician Authorization for Transfer form -Patient Transfer Acceptance or Refusal form - Physician Certification Medically for Transfer form -Transfer Summary form. . . Documentation: The following shall be documented in the patient's medical record and EMTALA log as appropriate: - Reason for patient transfer - Report given to transport team - Condition of patient prior to transport - Vital signs prior to transfer - Name of accepting physician at receiving hospital - Patient consent for transfer". Page 3 of this policy is the "Physician Assessment and Certification Transfer Summary" form; Under "Physician Certification" is the statement, "I have explained the following risks and benefits of being transferred/refusing transfer to the individual: [blank lines] Based on these reasonable risks and benefits to the individual and/or the unborn child(ren), and based upon the information available at the time of the individuals examination, the medical benefits reasonably expected from the provision of the appropriate medical treatment at another facility outweigh the increased risk, if any, to the individual's medical condition from effecting the transfer."

F) Record review of P3's medical record revealed:
1) Document titled, "Physician SOAP [Subjective, Objective, Assessment and Plan] Note" dated 01/07/2023 9:11 PM under "AP [Assessment Plan]" it states, "Contractions Concern for preterm labor No evidence of active labor at this time with no dilation and no evidence of PPROM [preterm premature rupture of the membranes] however given limitations of this facility will transfer to higher level of care for monitoring. . .". No evidence in this note of discussion with the patient regarding the risks and benefits of transferring.
2) Document titled, "Physician Assessment and Certification Transfer Summary" with admission date of 01/07/2023 the "Mode of Transport" states [name of air ambulance service]. There is a statement, "I have explained the following risks and benefits of being/refusing transfer to the individual" next to it is written "patient, mother." There is no further explanation of what the risks or benefits are.

G) Record review of P4's medical record revealed:
1) Document titled, "Physician ED [Emergency Department] H&P [History and Physical]" dated 01/06/2023 3:12 PM under "A/P [Assessment Plan]" it states, ". . . Suicidal ideation/posturing Patient with changing story throughout visit however given nature of injury I feel this is reflective of suicidal ideation. . . . Will consult psych [psychiatry] for likely transfer for inpatient management/evaluation." No evidence in this note of discussion with the patient regarding the risks and benefits of transferring.
2) Document titled, "Physician Assessment and Certification Transfer Summary" with admission date of 01/06/2023 the "Mode of Transport" states "EMS." There is a statement, "I have explained the following risks and benefits of being/refusing transfer to the individual" next to it is written "patient." There is no further explanation of what the risks or benefits are.

H) Record review of P6's medical record revealed:
1) Document titled, "Physician SOAP Note" dated 02/05/2023 10:21 AM states, "Hypotension [low blood pressure] likely 2/2 [secondary to] acute liver failure. . . will initiate transfer to higher level of care. . .Possible GIB [gastrointestinal bleed] pt [patient] reports month long hx [history] of dark, sticky stools, has had [about] 3 point drop in H&H [hemoglobin and hematocrit, labs to assess for blood loss] over past month. . . higher level of care as above." No evidence in this note of discussion with the patient regarding the risks and benefits of transferring.
2) Document titled, "Physician Assessment and Certification Transfer Summary" dated 02/05/2023 the "Mode of Transport" states [name of air ambulance service]. There is a statement, "I have explained the following risks and benefits of being/refusing transfer to the individual" next to it is written "patient; family." There is no further explanation of what the risks or benefits are.

I) Record review of P11's medical record revealed:
1) Document titled, "Physician SOAP Note" dated 03/24/2023 6:33 PM on page 4 it states, "STEMI [heart attack]. . . Cardilolgy [sic] consulted [provider from accepting hospital] who confirmed STEMI. . . Discussed with pt [patient] who agree w/ [with] plan. She understands she will be flown to [name of city]." No evidence in this note of discussion with the patient regarding the risks and benefits of transferring.
2) Document titled, "Physician Assessment and Certification Transfer Summary" dated 03/24/2023 the "Mode of Transport" states "Air [name of air ambulance service]." There is a statement, "I have explained the following risks and benefits of being/refusing transfer to the individual" next to it the lines are blank. There is no further explanation of what the risks or benefits are.

J) Record review of P12's medical record revealed:
1) Document titled, "Physician SOAP Note" dated 01/11/2023 12:37 PM states, "Suicidal ideation with suicide attempt in setting of bipolar disorder and depression, non-compliant with medications. Will work to transfer to inpt psych [inpatient psychiatry] for eval [evaluation] and treat." No evidence in this note of discussion with the patient regarding the risks and benefits of transferring.
2) Document titled, "Physician Assessment and Certification Transfer Summary" with an admission date of 01/11/2023 the "Mode of Transport" states "ground." there is a statement, "I have explained the following risks and benefits of being/refusing transfer to the individual" next to it the lines are blank. There is no further explanation of what the risks or benefits are.

K) Record review of P13's medical record revealed:
1) Document titled, "Physician SOAP Note" dated 02/01/2023 1:21 PM under "AP" it states, "Suicidal ideation, Schizophrenia Pt with active SI [suicidal ideation] but denies current plan. State hallucinations and impulses have been worse lately and requests inpt treatment. Will work to transfer for inpt psych eval." No evidence in this note of discussion with the patient regarding the risks and benefits of transferring.
2) Document titled, "Physician Assessment and Certification Transfer Summary" with an admission date of 01/11/2023 the "Mode of Transport" is blank. There is a statement, "I have explained the following risks and benefits of being/refusing transfer to the individual" next to it the lines are blank. There is no further explanation of what the risks or benefits are.

L) During an interview on 04/12/2023 at 1:24 PM with S6, MD it was asked if the risks of transferring is discussed with a patient. It was stated, "Yes, we usually talk about if deterioration happens, accidents, and it depends on more specifics related to the patient." When asked where this would be documented S6, MD referred to the "Physician Assessment and Certification Transfer Summary" form, a copy was provided by surveyor and S6, MD pointed to the line next to the statement, "I have explained the following risks and benefits of being/refusing transfer to the individual." Confirmed with S6, MD that this line is intended for an explanation of the risks discussed with patient and not intended to list who the risks were discussed with.

M) During an interview on 04/12/2023 at 1:50 PM with S1, Administrator it was confirmed that based on the facility policy titled, "Transfer of Patient to Another Facility" revised 10/21/2021 when it states, "Transfer papers shall be completed: . . . Physician Certification Medically for Transfer form -Transfer Summary form. . ." this means there should not be any blanks where information is required.