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Based on record review, staff interviews, review of the facility's records/documentation, policies and procedures, the facility failed to ensure compliance with 42 CFR Section 482.24 (Special Responsibilities of Medicare Hospitals in Emergence Cases) as:

1) the facility failed to ensure there were written policies and procedures in place to respond to situations in which a particular speciality is not available or the on-call physician could not respond because of circumstances beyond the physician's control. In addition, the medical staff by-laws and/or the facility's policies and procedures did not define the responsibility of the on call physicians to respond, examine and treat patients with an emergency medical condition (EMC);

2) the facility did not ensure that an individual who was feeling ill, came to the facility and requested to be seen in the emergency department (ED), was seen and provided a medical screening examination at the time of his/her request for 1 of 21 patients (Patient #1) in the active case sample, and,

3) the facility failed to ensure documentation to determine if an individual at a hospital who has an emergency medical condition (EMC) that has not been stabilized, that the hospital may not transfer the individual unless, 1) the transfer is an appropriate transfer, and the individual (or a legally responsible person acting on the individual's behalf) requests the transfer, after being informed of the hospital's obligations under this section and of the risk of transfer, with the request completed in writing and indicating the reasons for the request as well the individual's awareness of the risks and benefits of the transfer; 2) A physician has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual, with the certification containing a summary of the risks and benefits upon which it is based; and 3) A transfer to another medical facility is appropriate only in those cases in which: (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual's health, and; (ii) The receiving facility has available space and qualified personnel for the treatment of the individual; and has agreed to accept transfer of the individual and to provide appropriate medical treatment; (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual's emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, and results of any tests and the informed written consent or certification (or copy thereof); and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer, for 2 of 21 patients (Patients #5 and #9) in the active case sample.

Findings include:

Cross reference to findings at C2404, C2406 and C2409.

Based on a review of the facility's policies and procedures, administrative documentation and staff interview, the facility failed to ensure there were written policies and procedures in place to respond to situations in which a particular speciality is not available or the on-call physician could not respond because of circumstances beyond the physician's control. In addition, the medical staff by-laws and/or the facility's policies and procedures did not define the responsibility of the on call physicians to respond, examine and treat patients with an emergency medical condition (EMC).

Finding includes:

On 3/8/11, review of the facility's policy and procedure, "Emergency Department - On Call Physicians," CAH Policy No. 501.180.1 dated 1/15/01, found the policy did not address procedures to be followed if the on call physician could not respond due to circumstances beyond his/her control, such as a personal illness, transportation failures, etc.

On 3/10/11 at 4:00 P.M., during an interview and concurrent review of Policy no. 501.801.1 with the Interim Administrator on 3/10/11 at 4:00 P.M., he/she verified there was no written procedure in the existing policy to address the requirement at ?489.24(j)(2)(i). Review of the facility's Medical Staff By-Laws, including the Medical Staff Rules, stated at p. 5, section 3. General Conduct of Care, that "...The emergency room will be staffed by 'on call' physicians contracted by the hospital...On-call ER Physicians will be required to be at the emergency room within twenty minutes of being called." There was however, no other documentation that addressed the requirement for procedures to be followed if the on call physician could not respond due to circumstances beyond his/her control.

Additional review of the emergency group physician contractor services agreement (version 2/10) and supplemental agreement of 7/30/10 did not include reference(s) that defined the responsibility of the on call physicians to respond, examine and treat patients with an EMC.

Based on record review, staff interviews, review of the facility's record/documentation, policies and procedures, the facility, which has a dedicated emergency department, did not ensure that an individual who was feeling ill, came to the facility and requested to be seen in the emergency department (ED), was seen and provided a medical screening examination at the time of his/her request for 1 of 21 patients (Patient #1) in the active case sample.

Finding includes:

The SA conducted an EMTALA investigation at the facility from 3/8/11 to 3/11/11 based on a complaint allegation that an individual (Patient #1) who was feeling ill and requested to be seen in the emergency department on 8/28/10, was denied that request. The denial was the result of licensed staff following a nursing memo, "Employee ER Visits" dated 4/23/10 that specifically stated how employees were to be seen in the ED. The 4/23/10 memo stated, "If you are not currently working a shift, you may be seen in the ED...If you are currently working you may not be seen in the ED unless you have been excused from work by either the charge nurse or my self (the Chief Nurse Executive). This means you have to ask, you may not simply inform the charge nurse you are going to the ER. You may not check yourself in to the ED on your breaks. People who are feeling ill will only be excused from work if there is enough other staff on duty to provide safe patient care...Any one leaving a work shift to be seen in the ER without being released from work will be considered to have 'abandoned their shift' and will be subject to disciplinary action."

Patient #1, an employee of the facility, was not assessed, triaged or seen in the facility's ED until approximately two hours after his/her request to be seen in the ED. Patient #1 was thereafter provided a medical screening exam and transferred via ambulance to a recipient hospital to obtain a CT scan. The ED physician's diagnosis per his ED entry at 12:55 P.M. on 8/28/10 prior to the patient's transfer was abdominal pain, possible acute appendicitis. The patient was found to have a ruptured appendix and had surgery at 6:00 P.M. at the recipient hospital on 8/28/10.

The SA's investigation substantiated the 8/28/10 incident involving Patient #1. On 3/9/11 at 9:00 A.M., interview with the licensed staff (RN #1) who encountered Patient #1 in the facility prior to the start of Patient #1's work shift, verified what occurred. RN #1 said she had been passing medications for the facility's long term care residents when Patient #1 said he/she did not feel good and was having abdominal pain. Patient #1 told RN #1 the abdominal pain had worsened by 5:00 A.M. that morning. RN #1 stated that Patient #1 said, "I think I want to be seen in the ER." However, because Patient #1's shift was going to start within five minutes at 9:00 A.M. that day, RN #1 initially asked why he/she did not call two hours before (sick call notification), asked more questions about the pain and recalled a memo if an employee who was sick and made a request to be seen in the ED, that the employee would have to be seen at the end of their shift.

As a result, RN #1 stated she placed a call to the CNE first and was told by the CNE, "(Patient #1) knows the rule, why didn't (he/she) call two hours earlier? (He/she) knows the rule--the rules affect everyone." The CNE stated Patient #1 could be seen after his/her work shift ended and told RN #1 to monitor Patient #1 in the interim.

Patient #1 was not assessed, triaged or admitted into the ED on 8/28/10 although his/her initial presentation to the facility requesting to be seen in the ED occurred at approximately 9:00 A.M. Instead, RN #1 visually monitored Patient #1 until approximately 11:00 A.M. after Patient #1 stated to RN #1 that he/she could no longer withstand the pain. Thereafter, Patient #1 was seen by the ED physician after the ED physician found out about Patient #1's condition and admitted the patient to the ED.

The SA's investigation revealed that a corporate or "internal EMTALA investigation" of the 8/28/10 incident was completed by the Regional Corporate Compliance Officer (RCCO) in November 2010. The facility identified the violations and their actions resulted in the suspension of administrative personnel in January 2011. This was confirmed by the RCCO. In addition, the facility's entire staff underwent mandatory "General Compliance Training" sessions given by the RCCO. The compliance training was completed by the staff in February 2011 and a written test was also given.

The SA also found during its on-site EMTALA investigation, that based on the various staff interviews conducted between 3/8/11 through 3/11/11, their understanding of the EMTALA requirements was more defined and they understood that any patient or employee who was ill and requested to be seen in the ED would be seen in the ED. The various staff also verbalized the same was for any individual who presented to the facility and requested to be seen in the ED. In addition, RN #1 acknowledged in his/her 3/9/11 interview that there had been no other instances of similar events after the 8/28/10 incident. RN #1 said the "final rule" was the fact the 4/23/10 memo to call the CNE no longer existed and anyone could be seen in the ED. In a 3/10/11 interview, the CNE said a follow-up 12/3/10 nursing memo, superseding the 4/23/10 memo, was not a policy and their policy was to follow the EMTALA law. During a 3/9/11 interview with the RCCO, she said the practice which staff were following based on the CNE's nursing memos "has stopped."

The SA found the facility had no other allegations or investigations similar to the 8/28/10 incident and has not been cited for any other EMTALA violation(s).

Based on record reviews, staff interview and a review of the facility's policies and procedures, the facility failed to ensure documentation to determine if an individual at a hospital who has an emergency medical condition (EMC) that has not been stabilized, that the hospital may not transfer the individual unless, 1) the transfer is an appropriate transfer, and the individual (or a legally responsible person acting on the individual's behalf) requests the transfer, after being informed of the hospital's obligations under this section and of the risk of transfer, with the request completed in writing and indicating the reasons for the request as well the individual's awareness of the risks and benefits of the transfer; 2) A physician has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual, with the certification containing a summary of the risks and benefits upon which it is based; and 3) A transfer to another medical facility is appropriate only in those cases in which: (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual's health, and; (ii) The receiving facility has available space and qualified personnel for the treatment of the individual; and has agreed to accept transfer of the individual and to provide appropriate medical treatment; (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual's emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, and results of any tests and the informed written consent or certification (or copy thereof); and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer, for 2 of 21 patients (Patients #5 and #9) in the active case sample.

Findings include:

On 3/10/11, as part of the sample record review of emergency room patients, Patients #5 and #9 were found to have been "transferred" by their attending emergency room (ED) physicians. The ED documentation noted the transfers involved discharging these patients from the ED "to go directly to" another hospital for further work-up. The facility's ED physicians called the recipient hospital to obtain acceptance of the transfers for Patients #5 and #9. However, there was no physician certification found in both patient's ED records and there were no consent forms or other transfer documentation, and no evidence that the recipient hospital was provided with copies of all medical records of both patients. The record reviews of the two sampled ED patients found the following:

1. Patient #5's ED admission was on 7/14/10 at 10:24 P.M. The patient was brought to the ED by his/her spouse for complaints of mid-upper quadrant and abdominal pain, radiating to the patient's back with pain level of 10 out of 10. The pain was similar to gallbladder pain the patient had before. The onset of pain was the same day as presentation to the ED. A medical screening examination (MSE) was done by the ED physician, who noted Patient #5 had a history of a cholecystectomy with similar symptoms/onset. Treatment was ordered and provided and the ED physician noted, "without LFTs (liver function tests) or imaging - likely will require transfer to (another hospital). 2131 spoke with (physician at recipient hospital) - will accept transfer. Pt very stressed, (illegible writing) PN only slightly improved will give Toradol and transfer 2154 after Toradol - patient states PN 50% less now 'Can take a drive.'" A ED nursing entry at 10:05 P.M. noted, "Pt (illegible) discharged to (family), to drive him to NHCH ER for further tx, instruct given to pt...verbalizes understanding of instruct & to go directly to NHCH ER. Pt in good condition." The discharge instructions stated, "go directly to North Hawaii Community Hospital Do not eat." There was no patient consent for transfer or other transfer documentation/checklist found in Patient #5's ED record. The patient was discharged from the ED in a private vehicle.

2. Patient #9's ED admission was on 12/10/10 at 4:00 A.M. and was seen for complaints of left lower quadrant pain with progressive worsening for 3 days. The patient's pain radiated across the abdomen, but had no previous similar episode. The patient denied fever, chills, nausea, vomiting, diarrhea, no melena or hematochezia. An MSE was done by an ED physician who diagnostic impression was abdominal pain; but noted it was suggestive of diverticulitis, although the patient was negative for fever and blood in the stool, except for significant tenderness on exam. The ED physician noted, "...obtaining a CT to confirm a diagnosis is necessary prior to initiating treatment, also to exclude any surgical diagnosis." The patient...agreeable to going to another hospital for further work-up. The facility's ED physician discussed Patient #9's status with a physician at the recipient hospital, who accepted the transfer. It was noted that Patient #9 had declined pain medication. The ED physician noted the patient's disposition was to transfer to the recipient hospital by "...POV (private vehicle). Follow-up with: go to (recipient hospital)." It is not clear what was faxed to the patient's private physician. On the patient's discharge sheet, the ED physician wrote: "Go to (recipient hospital) ER."

On 3/11/11 at 12:30 P.M., the Chief Nurse Executive (CNE) was asked about the hospital's transfer requirements for patients such as for Patients #5 and #9. The CNE stated if patients left in their private vehicle, they were considered a discharge and not a transfer. The CNE said "that's the way we've been handling it, as a discharge. If they went by an ambulance, it's a transfer." The CNE said the ED could not control what would happen to the patients otherwise. The CNE stated if it was written as a transfer (by the ED physician) in the record, "it shouldn't be."

The facility's policy and procedure, "Discharge From The Emergency Room" (dated 5/21/01) noted the nursing staff was to follow procedures for discharging patients from the ED by following a procedure in another policy, "Transfers of Patient With Emergency Medical Condition" (CAH policy: 501.180.3; dated approved: 10/15/97). The latter policy also included a statement, which said to follow an attached procedure - 501.180.3.1, "Emergency Care, Transfers (COBRA) (dated 9/15/2000). The "procedure" was found to be a corporate policy (PAT 0003) with one of the stated purposes to "...provide criteria for appropriate transfer to another facility for definitive treatment. To provide the patient needing continuing or follow-up care at another medical facility with a means of safe transportation, continuity of care, education, and support."

On page 3 of policy PAT 0003, it also stated, "D. Once 'emergency services and care' have been provided, transfer may be considered if the patient is 'stabilized' or, if not stabilized, the patient has requested a transfer or the physician has certified that the transfer is medically necessary. Before the hospital may transfer a patient the hospital must satisfy the following conditions:...2. The patient has been informed of the reasons for the transfer, all associated risks and benefits, and has consented to the transfer to another medical facility. E. The attending physician (from the transferring hospital) is responsible for care of a patient enroute to the receiving facility...G. Mode of transfer shall be determined by the physician. H. All pertinent medical information (e.g., ED forms, x-rays, lab reports, etc.) will accompany the patient."

Further, another policy and procedure, "Transfer From Kohala Hospital To Another Facility" (dated 3/5/10), noted for emergent transfers, either the physician or the charge nurse was to call to schedule the transfer via ambulance transport and complete a Cobra transfer form. With regard to Patients #5 and #9, the ED physicians documented both patients were to be transferred to another facility in the patients' own private vehicles. However, a review of the clinical documentation and review of the various ED policies and procedures found the facility failed to ensure the appropriate transfer requirements were met that would have included physician certifications, consent to transfer and release of all pertinent medical records to the recipient hospital.