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Based on policy and procedure review, closed medical record reviews and staff interviews the facility failed to ensure compliance with 42 CFR 489.24.

Findings included:

Based on policy and procedure review, closed medical record reviews and staff interviews the physician failed to closely match completion of the written certification for transfer to the date and time of the transfer in 3 of 8 patients transferred from the Dedicated Emergency Department (DED) (#26, #28, #27).

~ cross refer to 489.24(e)(1)-(2) Appropriate Transfer - Tag A2409

Based on review of policy and procedures, the Emergency Room Log, closed medical records and staff interviews staff failed to ensure maintenance of an accurate central log of individuals presenting to the hospital's Dedicated Emergency Department (DED).

The findings include:

Review on 5/16/2012 of the facility policy "EMTALA Compliance, Including Patient Transfers (Emergency Medical Treatment and Labor Act) dated 03/12 revealed "Procedure...VII. Notice and Documentation Requirements...B. Individual Log. The hospital will maintain a log identifying at least (i) each individual who "comes to the hospital emergency department" as defined in Section I seeking assistance, and (ii) the disposition of the case (individual refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, or was discharged).

Review on 5/16/2012 of the DED log from both co-located sites of the hospital from November 2012 through April 2012 revealed greater than 200 missing patient dispositions over the time period.

Record review on 5/17/2012 for Patient #2 revealed a 42 year old who presented to the hospital's DED on 4/12/2012 at 1724 for a chief complaint of chest pain. Review of the DED log indicated the patient had a disposition status of discharged. Record review for the patient revealed the patient was admitted.

Record review on 5/17/2012 for Patient #5 revealed a 63 year old who presented to the hospital's DED on 4/13/2012 at 1203 for a chief complaint of chest pain. Review of the DED log indicated the patient had a disposition status of discharged. Record review for the patient revealed the patient was admitted.

Record review on 5/17/2012 for Patient #11 revealed a 55 year old who presented to the hospital's DED on 4/13/2012 at 2230 for a chief complaint of chest pain. Review of the DED log indicated the patient had a disposition status of discharged. Record review for the patient revealed the patient was admitted.

Record review on 5/17/2012 for Patient #19 revealed a 59 year old who presented to the hospital's cardiac catheterization laboratory via Emergency Medical Services (EMS) from a referring hospital on 5/03/2012 at 1543 for a chief complaint of STEMI. Review of the DED log revealed the patient's name of "Asheville STEMI" with no recorded disposition. Record review for the patient revealed the patient was admitted.

Interview on 5/17/2012 at 1700 with administrative staff confirmed there were multiple (greater than 100) missing dispositions in the DED emergency central log. Interview failed to reveal any further documentation of the missing dispositions. Further interview confirmed the inaccuracies in the central log for Patient #2, #5, #11 and #19. Interview revealed facility staff failed to follow facility policy by failing to maintain an accurate record of each patient's disposition from the hospital's DED.

Based on policy and procedure review, closed medical record reviews and staff interviews the physician failed to closely match completion of the written certification for transfer to the date and time of the transfer in 3 of 8 patients transferred from the Dedicated Emergency Department (DED) (#26, #28, #27).

The findings include:

Review on 5/17/2012 of facility policy "EMTALA Compliance, Including Patient Transfers (Emergency Medical Treatment and Labor Act) dated 03/12 revealed "Procedure...IV. Transfer of Unstabilized Individual for Medically Indicated Reasons...(2) The physician certifies in writing that the expected benefits of the transfer outweigh the increase risk of transfer to the individual...The physician must sign a certification...(a) The emergency physician/on-call physician will complete and sign the CHS EMTALA Transfer Form, stating that, based on the information available at the time of transfer, the medical benefits reasonably expected from the care anticipated at the receiving hospital outweigh the risks of transfer..."

1. Medical record review of patient #26 revealed a 60 year old presenting to the DED on 12/07/2011 at 0320. Record review revealed the chief complaint was shortness of breath. Record review revealed the patient was triaged a level 3 Urgent. Record review revealed the reason for transfer was "Medically indicated", with the Medical benefit "Obtain level of care/services not available at this facility - no Tele(metry) beds". Review of the "EMTALA TRANSFER FORM" revealed written certification for transfer documented by the physician on 12/07/2011 at 0702. Further review revealed the patient left the DED for transfer at 1555 on 12/07/2011 (8 hours and 53 minutes after physician certification). Record review revealed no further documentation by the physician prior to the patient leaving the DED.

Interview with the Director of Patient services for the DED on 5/17/2012 at 1615 confirmed the written physician certification was completed at 0702 and the patient left the DED at 1555. The interview revealed there was no further documentation available of a physician reassessment of the patient prior to the patient leaving the DED.

2. Medical record review of patient #28 revealed a 48 year old presenting to the DED on 5/10/2012 at 1345. Record review revealed the chief complaint was suicidal ideation. Record review revealed the patient was triaged at 1359 as a level 2 on a 5 scale - Emergent. Review revealed a telemedicine psychiatric consultation was completed 5/10/2012 at 2200 and decided the patient should be involuntarily committed. Record review revealed the reason for transfer was "Medically indicated", with the Medical benefit "Obtain level of care/services not available at this facility". Review of the "EMTALA TRANSFER FORM" revealed a physician signature for written certification with no date or time of the certification. Further review revealed the patient left the DED for transfer at 1815 on 5/12/2012. Record review revealed no further documentation by the physician prior to the patient leaving the DED.

Interview with the Director of Patient services for the DED on 5/17/2012 at 1615 confirmed there was no documented date and time of the physician certification for transfer. The interview revealed there was no further documented evidence available of a date and time of physician certification or of any physician reassessment of the patient prior to the patient leaving the DED.



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3. Medical record review of patient #27 revealed a 26 year old presenting to the DED on 5/13/2012 at 1345. Record review revealed the chief complaint was severe abdominal pain with history of vomiting and Human Immunodeficiency Virus (HIV). Record review revealed the patient complained of pain at a rate of 7 on a 10 point scale with 10 being the worst pain. Record review revealed the patient was triaged a level 3 Urgent. Record review revealed the reason for transfer was "Medically indicated", with the Medical benefit "Obtain level of care/services not available at this facility". Review of the "EMTALA TRANSFER FORM" revealed written certification for transfer documented by the physician on 5/12/2012 at 1641. Further review revealed the patient left the DED for transfer at 1954 on 5/12/2012 (3 hours 13 minutes after physician certification). Record review revealed no further documentation by the physician prior to the patient leaving the DED.

Interview with the Director of Patient services for the DED on 5/17/2012 at 1545 confirmed the written physician certification was completed at 1641 and the patient left the DED at 1954. The interview revealed there was no further documentation available of a physician reassessment of the patient prior to the patient leaving the DED.

NC00080079