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Based on observation and interview, the facility failed to post signs regarding patient rights under EMTALA (Emergency Medical Treatment and Active Labor Act) in places where they were likely to be seen by patients walking in to the emergency department (ED) and by patients in the ED waiting room. The deficient practice had the potential to cause patients to be unaware of their rights, thereby reducing the chance of a complaint in the event the hospital did not uphold a patient's rights.

Findings:

In an observation and interview on 12/20/17 at 10:05 a.m., no signs regarding EMTALA were visible at the exterior ED entrance, in the vestibule between the sliding glass doors forming the ED entrance, at the security counter just inside the ED entrance, or at the ED registration window. The Clinical Director of Quality Services (CDQS) pointed out the EMTALA sign to the surveyor. The EMTALA sign was around a corner from the ED registration window, mounted on a wall adjacent to a set of double doors leading from the registration area into the ED; the sign was not in line of sight from the ED exterior entrance or the ED registration window. A waiting area near the ED registration window contained a wall-mounted flip chart displaying notices regarding the facility's privacy practices in English and Spanish. The flip chart did not include a notice regarding patient rights under EMTALA. The CDQS acknowledged the flip chart did not contain an EMTALA notice and stated the sign outside the ED double doors was intended to serve both the registration area and the waiting area. The CDQS stated another EMTALA sign was posted in the ambulance entrance.

Based on observation, interview and record review, the facility failed to accept one of 21 patients (Patient 1) to the Emergency Department from a referring hospital on 12/4/17 who required neurosurgical services that were within the capacity and capability of the facility.

Patient 1 was initially admitted to the Emergency Department (ED) of General Acute Care Hospital ( GACH) 1 for altered mental status and intracranial bleed. Patient 1 was transferred to GACH 3 for higher level of care because the facility (GACH 2) refused to admit Patient 1 due to his insurance status.


The deficient practice could potentially delay the treatment and compromise the health and safety of Patient 1.

Findings:

Patient 1 was brought in by ambulance to GACH 1 because of altered mentation noted by workers at a local coffee shop. Review of the Ambulance records showed Patient 1 arrived at the Emergency Dept. on 12/3/17 at 10:09 PM. The chief complaint indicated altered level of consciousness.

Review of a document from GACH 1 titled, "Default Flowsheet Data dated 12/3/17 indicated Patient 1 arrived in the GACH 1 ED on 12/3/17 at 2216 (10:16 PM). The ESI (Emergency Severity Index) Priority: 2 Emergent..."

Review of the CT (Computerized Tomography) Head without contrast for patient 1 done on 12/4/17 showed the following results:

"1. Bifrontal lobe hemorrhagic contusions with surrounding edema suggests that these could be at least 10-11 hours of age; hemorrhagic contusion. High convexity bilateral frontal lobe hemorrhagic cortical contusions.

2. Right frontal subdural hematoma measuring 2.0mm. 3.4 mm subdural hematoma measuring 2.0 mm. 3.4 mm subdural hematoma anterior to the left temporal lobe tip

3. Left frontal epidural hematoma measuring 2.5 mm with associated focal pneumocephalus

4. Left frontal bone fracture extending through the anterior and posterior aspect of the left frontal sinus with hematoma within the left frontal sinus the fracture extends along the superior aspect of the left frontal bone crossing the left superior coronal suture and extending into the posterior superior sagittal suture with diastases of the posterior superior sagittal suture and focal pneumocephalus surrounding the posterior aspect of the superior sagittal sinus with soft tissue density suggesting possible thrombosis of the posterior superior sagittal sinus and or hematoma.

5. Small anterior falx cerebri dural hematoma

6. Left frontal sinus fracture with hematoma within the sinus

7. Ecstasia of the basilar artery tip cannot exclude basal artery aneurysm

8. Focal subarachnoid hemorrhage left anterior sylvian fissure."


Record review of the Notes by MD 1, the GACH 1 Emergency Dept. physician, dated 12/4/2017 at 1:33 AM, showed the following:
" Patient with altered mental status out in public
Reports of patient being at another facility but not able to get any records from outside hospitals
Found to be febrile and altered on intial (sic) evaluation...
CT head for continued ALOC (Altered level of consciousness)
Found top have intracerebral hemorrhage, frontal sinus fx (fracture) suggesting fracture
Subdural/epidural hemorrhage...

Emergency Department Diagnosis:
1. Altered mental status
2. Fever
3. Traumatic cerebral hemorrhage..."

During a telephone interview with MD 1 on 12/12/17 at 1:30 PM, he confirmed that he examined Patient 1 on 12/3/17. He said the patient had a fever and a septic work up was done. He said, "There was nothing specific that we could put our hat on that would have caused the altered mental status. He (Patient 1) had no obvious facial trauma. I decided to do a CT of the head and it showed intracranial bleed."

MD 1 also said that there were no neurosurgical services in the GACH 1 facility. He called the facility (GACH 2) Emergency Dept. It was around 1AM. He spoke with MD 2 who was the on-call neurosurgeon at the GACH 2 ED on 12/3/17. MD 1 said MD 2 did not actually refuse but he asked if the patient was a XYZ Insurance member. MD 1 said they checked their records and found out he did not have XYZ Insurance.

MD 1 said he called GACH 3 after talking to MD 2 and spoke to MD 3, the neurosurgeon on-call at the GACH 3 ED. MD 1 acknowledged that he told MD 3 that GACH 2 would not take the patient because he was not an XYZ insurance member. MD 1 said that MD 3 agreed to accept Patient 1 in the GACH 3 Emergency Dept.

Review of the document from GACH 1 titled, "Physician Assessment and Certification Patient Transfer Under EMTALA/COBRA" dated 12/4/17 indicated, " Diagnosis: Intraparenchymal bleed, Subdural/epidural bleed... Section 1B. Reason for transfer: Neurosurgical Service...time 3AM...Section 2A. Receiving Hospital GACH 3.Time hospital accepted 0115(1:15AM)...mode of transport- CCT (Critical Care Transport)..."

During a telephone interview with MD 3 on 12/12/17 at 3 PM, he confirmed that he spoke to MD 1 on 12/4/17 around 1 AM regarding Patient 1. He said he asked MD 1 why he did not call GACH 2. He said MD 1 told him that GACH 2 could not accept the patient because he did not have XYZ insurance. MD 3 said he told MD1 that GACH 2's refusal to take the patient based on insurance is an EMTALA (Emergency Treatment and Labor ACT) violation. MD 3 said that his full conversation with MD 1 was recorded in the hospital transfer line. GACH 3 provided the surveyor via e-mail on 12/12/17 an electronic copy of the recorded conversation between MD 1 and MD 3.

The electronic copy of telephone conversation on 12/4/17 between MD 1 and MD 3 was reviewed. In the recorded message, MD 3 asked MD 1, "Did you call GACH 2?" MD 1's response was," He is a non-member. They won't accept him if you are not a member. It has to be GACH 3 or GACH 4 not unless you don't have the capability or bed."

During an interview with MD 2 on 12/20/17 at 2:23 PM, MD 2 stated he recalled a 30 second discussion with MD 1 regarding a patient with frontal hemorrhage. He stated that the patient was presented as a non member of XYZ insurance. He denied declining admission but he told MD 1 to "call around" to obtain records from other hospitals but said would take the patient if necessary. He acknowledged it might have been handled differently if Patient 1 was an XYZ insurance member since he would have the records. MD 2 confirmed he did not keep a record of his conversation with MD 1 on 12/4/17.

Review of the facility's Neurosurgery On-Call list for December 2017 indicated MD 2 was the neurosurgeon on call on 12/3/17 from 8AM to 8AM.


Review of a document from the facility showed, " GACH 2 Neurosurgery Center of Excellence". The document listed the following services: Neurosurgery-1800 operations/year... neuro-critical care..functional neurosurgery...skull base multidisciplinary care..."

Record review of the 2016 Plan for Provision of Patient Care showed the facility has a Neuro Medical/Surgical Unit. It consists of a total of 24 Med/Surg inpatient beds... Patients are admitted with a variety of diagnoses, including: neurosurgical and neuroscience diagnosis, including post-craniotomy, spinal surgeries, Epilepsy, Stroke, Neurological Tumors, and movement disorders...

During an interview with the Director of Nursing on 12/20/17 at 1:01PM, she stated that the GACH 2 ED was on diversion only one time on 12/2/17 for 2 1/2 hours because the CT Scan was down".

Record review of the facility's Emergency Dept. Charge Nurse's Sheet showed " Date 12/2/17 CT down- 0905 - 1100, divert" . There was no evidence that the facility was on diversion on 12/3/17 or 12/4/17.


Review of the facility's policy and procedure titled, "Emergency Medical Screening Examination, Treatment and Transfer-EMTALA" dated 8/8/16 indicated the following:

"1.0 Policy Statement: 1.2 The hospital prohibits actions that would discourage an individual from seeking emergency medical services and will provide an MSE (medical screening examination) and necessary stabilizing treatment regardless of the individual's health plan membership, insurance status, method of payment, participation in or eligibility for government programs, or participation in or eligibility for hospital sponsored financial assistance programs. No individual with an EMC will be refused care due to inability to pay.

5.0 Provisions/Procedures: 5.1.1 The hospital will not delay the provision of a medical screening evaluation and/or necessary stabilizing treatment in order to inquire about an individual's method of payment and /or insurance status.

5.6 Transfer Requirements- Transfer in 5.6.1 The hospital will not refuse to accept, from a referring hospital, an appropriate EMTALA transfer of an individual with an unstabilized emergency medical condition who requires specialized capabilities if the hospital has the capability and the capacity to treat the individual and if the referring hospital does not have the capability or capacity to provide medically needed services.

Under Section 5.10 On-Call Physicians- List and Responsibilities: 5.10.6 An on-call physician will not refuse to accept the transfer of an unstabilized emergency patient in need of a higher level of care (including specialized care), if the hospital has the capability and capacity to treat the EMC (Emergency Medical Condition)."