HospitalInspections.org

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Based on observation, interview, record review and review of hospital policies and procedures, the hospital failed to develop and implement policies and procedures for evaluation, treatment and appropriate transfer or discharge of patients presenting for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to ensure patients receive a comprehensive medical screening examination by a qualified medical professional and stabilizing treatment prior to transfer or discharge risks poor health care outcomes, injury, and death.

Findings included:

1. The hospital failed to ensure that staff documented on the hospital's "Leaving Hospital Against Medical Advice" form when patients decided to leave the hospital's ED against medical advice (AMA) for 1 of 3 patients AMA.

Cross Reference: A- 2407

Findings included:

1. The hospital failed to ensure that the receiving facility and receiving physician accepted the patient in transfer prior to leaving the Emergency Department for 1 of 5 patients transferred.

2. The hospital failed to ensure that the medical records for 1 of 5 patients transferred to another facilitiy included the Authorization for Transfer form required by hospital policies and procedures.

Cross Reference Tag A-2409

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Based on interview, document review and review of hospital policies and procedures, the hospital failed to obtain, or attempt to obtain, a written refusal of care for 1 of 3 patients leaving against medical advice (AMA) (Patient #13).

Failure to obtain a written refusal risks patients' lack of understanding of the risks and benefits of remaining at the facility until an appropriate transfer for care (admission, discharge, or transfer) could be facilitated resulting in possible patient injury or death.

Findings included:

1. Review of the hospital's policy titled, "Leaving Against Medical Advice, Ricky's Law & Elopement," number 11566879, effective date 04/22, showed that if a patient with decision-making capacity insists on leaving, the discharge included:

a. Advice of signs and symptoms and/or when to seek medical attention

b. Make follow-up arrangements with other agencies as indicated, if possible

c. Provide prescriptions or supplies as needed to bridge the gap

d. Reconcile outstanding diagnostic results to be sure nothing serious was identified

e. Advise the patient or representative that he/she may return to the ED at any time

f. Patient signs AMA form

g. Offer to contact family or arrange transportation if unable to drive

h. Escort the patient with all belongings to the hospital exit for safety

i. Document the event, the reason the patient stated for leaving. Document exactly what the patient was told and actions taken.

2. Review of the medical records showed that a patient arrived in the ED on 07/01/23 at 7:48 PM with a complaint of weakness and fever. The patient was triaged upon arrival, and was seen by the Emergency Department (ED) provider at 7:54 PM. Laboratory and radiology testing were ordered. At 10:14 PM all ordered tests were resulted in the medical record. At 10:22 PM a bed was requested for admission to the hospital. Documentation by the provider showed that medical decsion making included that the patient had a urinary tract infection, but due to their profound weakness, would be admitted to the hospital. Diagnoses listed included acute cystitis without hematuria, weakness, and fever, unspecified cause. The medical record showed that the provider entered the patient dispostion as AMA on 07/02/23 at 1:11 AM. Nursing documentation showed that the admission bed request was cancelled at 1:13 AM. Nursing documentation showed that the discharge instructions were reviewed with the patient, including follow up care. The note showed that the patient verbalized understanding and agreed with the discharge plan. The patient left the ED with family on 07/02/23 at 1:33 PM (Patient #13).

3. On 12/06/23 at 2:00 PM, during an interview with the investigator, the Emergency Department Manager (Staff #2) stated that the medical record did not include an AMA form (Patient #13).

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ITEM #1: Transfer not accepted by the receiving facility and provider

Based on interview, document review and review of policies and procedures, the hospital failed to ensure that patients transferred to other facilities were accepted by the receiving facility and
provider prior to leaving the hospital for 1 of 5 patients transferred.

Failure to ensure that patients have been accepted by the receiving facility and provider, risks inappropriate transfer, delayed care, and poor patient outcomes.

Findings included:

1. Document review of the hospital's policy titled, "Emergency Department/FSED (Free Standing Emergency Department) Standards of Care," number 10105802, effective date 08/21, showed that transfer documentation was to be completed on all patients transferred to other inpatient medical facilities, hospitals, and psychiatric facilities.

2. Document review of the hospital's policy titled, "Transfer to Other Health Care Facilities," number 14187014, effective date 08/23, showed that an appropriate transfer is one in which:

a. The transferring hospital provides medical treatment within its capacity that minimizes the risks to the patient's health and, in the case of a woman in labor, the health of the unborn child

b. The receiving facility has available space and qualified personnel for the treatment of the patient and has agreed to accept the transfer and provide appropriate medical treatment

c. The transferring hospital provides the receiving facility with copies of all appropriate medical records of the examination and treatment performed. If test results or other records are not available at the time of transfer, they should be sent as soon as practical after the transfer

d. The transporting personnel are qualified and the necessary transportation equipment for life support is also transported with the patient.

3. Medical record review showed that Patient #1 arrived in the Free Standing Emergency Department (FSED) on 11/10/23 at 12:31 AM, with the complaint that they were 16 weeks pregnant with a vaginal problem. The provider saw the patient at 12:45 AM. Orders for an obstetric transvaginal ultrasound, lab testing, and pain medication were placed at 1:24 AM. Nursing notes showed that the patient was assisted to the bathroom. The patient called the nurse into the bathroom to see products of conception in the toilet. The provider was called into the room to assess. Documentation showed that the patient was discharged at 4:26 AM and discharge instructions were reviewed. The After Visit Summary (AVS) instructions showed that the patient was to head straight to the Trios Hospital for admission by Desert Sky OB/GYN.

4. On 12/07/23 at 9:03 AM, during an interview with the investigator, a physician provider (Staff #14) stated that the disposition tab could be filled in without actually finalizing the discharge. If the initial disposition information isn't changed when the patient disposition decision is changed, the AVS would show the instructions that were initially entered into the disposition screen. The provider enters the information into the disposition tab in the electronic medical record.

5. On 12/06/23 at 9:45 AM, during an interview with the investigator, the Director of Quality (Staff #1) stated that the complaint subject patient event was reviewed in a multidisciplinary huddle format. The hospital had reported the event to the Washington Department of Health and was still working through a proximate cause analysis. The provider reported that they intended to discharge the patient home, but did not change the information in the disposition tab.

6. Medical record review of the Trios Hospital medical record of the complaint subject patient (Patient #1) showed that the patient arrived in the Family Birth Center on 11/10/23 at 6:37 AM. The nursing note showed that the patient had been seen at Kadlec where she had a spontaneous abortion at 3:30 AM. The patient went home and called her provider who instructed her to go to the Trios Emergency Department to be evaluated. Upon arrival, the provider admitted the patient to the Family Birth Center for pain control, monitoring bleeding, and a confirming ultrasound regarding products of conception.


ITEM #2: Transfer documentation

Based on interview, document review, and review of hospital policies and procedures, patients transferred to other facilities did not have documentation on the Transfer Form as required by hospital policy for 1 of 5 patients transferred (Patient #1).

Failure to ensure that patients have completed documentation prior to being transferred to another facility risks inappropriate transfer, delayed care, and poor outcomes.

Findings included:

1. Document review of the hospital policy titled, "Transfer to Other Health Care Facilities," number 14187014, effective date 08/23, showed that the Emergency Department physician or the attending physician (if responsible for certifying a patient transfer) shall:

a. Ensure that an appropriate medical screening examination was performed for the patient in order to determine if an emergency medical condition exists

b. Certify on the Patient Transfer/Physician orders form that the benefit to the patient outweighs the risk of the transfer

c. Document on the Patient Transfer/Physician orders form the basis of the certification

d. Obtains informed consent for the transfer from the patient or legal representative

e. Contact the receiving physician to establish acceptance of the patient and document the name of the receiving physician and the time of acceptance on the Patient Transfer/Physician order form.

2. Medical record review showed that there was no Patient Transfer/Physician order form located in 1 of 5 records of patients transferred to other facilities (Patient #1).

3. On 12/06/23 at 9:45 AM, during an interview with the investigator, the Manager of the Free Standing Emergency Department (Staff #12) stated that there was no Patient Transfer/Phsycian order form for the complaint subject patient (Patient # 1) in their medical record.

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