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Based on interview, review of the ED central log, and review of policies and procedures, it was determined that for 8 of 20 patients (Patients 1, 5, 6, 7, 8, 14, 18, and 19), the hospital failed to fully develop and enforce EMTALA policies and procedures in the following areas:

42 CFR 489.20(r)(3) Maintenance of a central ED log;

42 CFR 489.24(e) Appropriate transfer of patients.

Findings:

Refer to findings identified at Tag A2405 regarding maintenance of a central ED log for Patients 1, 5, 6, 7, 14, 19, and 19.

Refer to findings identified at Tag A2409 regarding appropriate transfer of Patient 8.

Based on interview, review of the ED central log for patients who presented to SHUD ED for emergency services and review of policies and procedures, it was determined the hospital failed to enforce EMTALA policies and procedures to ensure maintenance of a central log that contained complete and accurate information.

Findings:

1. The hospital policy and procedure titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated as effective 09/26/2016 was reviewed. The policy stipulated, "Each facility maintains a central log of individuals who come the Emergency Department...seeking assistance, and indicate whether these individuals...Refused treatment; Were denied treatment; Were stabilized, admitted, transferred, or discharged; or Left the ED prior to being seen...The log contains the following information: The Patient's name, date of log entry, medical record and account numbers of Patients transferred to or form the Medical Center."

2. Review of the ED central log revealed entries for the following patients were incomplete:

- Patient 1 arrived at the ED on 05/22/2017 at 1904. The ED disposition section of the log was blank.
- Patient 5 arrived at the ED on 03/17/2017 at 0530. The ED disposition section of the log was blank.
- Patient 6 arrived at the ED on 05/06/2017 at 1210. The ED disposition section of the log was blank.
- Patient 7 arrived at the ED on 05/02/2017 at 1227. The log failed to include the chief complaint and the ED disposition section of the log was blank. - Patient 14 arrived at the ED on 05/30/2017 at 1439. The ED disposition section of the log was blank. - Patient 18 had two entries for the ED on 03/21/2017. Entry 1 reflected Patient 18 arrived at the ED at 0651. The log failed to include the chief complaint and the ED disposition section of the log was blank. Entry 2 reflected Patient 18 arrived at the ED at 0654. - Patient 19 arrived at the ED on 02/08/2017 at 1925. The ED disposition section of the log was blank. 3. Review of the ED central log dated 11/01/2016 through 06/12/2017 reflected a total of 19300 patients. The ED disposition section of the log was blank for 930 of those patients. The chief complaint section of the log was blank for 30 patients.

4. During an interview with the CNO, he/she confirmed documentation in the ED central log was incomplete.

Based on interview, review of ED medical records, and review of policies and procedures, it was determined that for 1 of 6 patients (Patient 8) transferred to other facilities the hospital failed to follow EMTALA policies and procedures to ensure appropriate transfers.

Findings:

1. The policy and procedure titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated as effective 09/26/2016 was reviewed. The policy stipulated "The transferring facility has completed the EMTALA transfer form; and...Sent to the receiving facility, copies of all medical records related to the emergency condition available at the time of the transfer, including at least:...A copy of the EMTALA form, including the Patient's informed written consent to transfer; and Certification of the transfer...An EMTALA Transfer Form is completed by the physician to document...The consent, request or refusal transfer by the Patient/legal representative."

3. Review of the medical record for Patient 8 revealed he/she arrived at the ED via car on 03/17/2017 at 2000 with an "ED Chief Complaint" of "Mental Health Crisis." The "ED Diagnosis" was recorded as "Bipolar 1 disorder...Psychosis, unspecified psychosis type and Elevated TSH." The "Acuity" was recorded as "ESI-2" and the "ED Disposition" reflected "Transfer to Another Facility...[Patient 8] should be transferred out to Riverbend."

Further review of the medical record revealed an "ED Provider Note" dated 03/18/2017 and signed by the physician at 0040. Documentation by the MD included, "1:05 AM Notified by RN that [Patient 8] is hypoxic...1:29 AM After evaluating the patient personally, it was clear that [he/she] was not protecting [his/her] airway...and [he/she] was intubated successfully...1:39 AM Spoke to Dr...who accepts the patient to the ICU."

The review of documentation in the medical record failed to reflect that the required EMTALA form had been completed for the transfer of Patient 8 to another facility.

4. During the medical record review for Patient 8 on 06/15/2017 at 1525, the CNO confirmed the patient was transferred to "Sacred Heart Riverbend...for respiratory failure." He/she confirmed the medical record for Patient 8 did not contain the required transfer documentation.

During an interview on 06/14/2017 at 1045 with the CNO, he/she stated services provided at the hospital did not include an intensive care unit. If a patient required treatment in an intensive care unit, the patient would be transferred to Sacred Heart Riverbend.