HospitalInspections.org

Based on record reviews and interview, the hospital failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals to ensure the emergency medical treatment and labor act (EMTALA) requirements were met by failing to include all patients on a central log; failing to provide a medical screening exam (MSE) to determine if an emergency medical condition (EMC) existed; failing to have patients who refuse stabilizing treatment after seeking emergency services sign that they have been informed of the medical risks and still want to leave Against Medical Advice (AMA); failing to provide an appropriate transfer; and failing to ensure there is documentation in the record explaining the risks and benefits of the transfer.

The cumulative effect of these deficient practices had the potential for all patients to be discharged/leave with an unidentified EMC which causes delays in necessary stabilizing treatment and may lead to deterioration of the patient's condition, including death.

Findings Include:

1. Review of a hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)" updated 01/22 revealed, "Each hospital will maintain a Central Log to track the care provided to individuals who come to the hospital seeking treatment, a. Every patient who comes to the ED or Labor and Delivery Department seeking treatment will be logged into the Central Log, b. All logs will be available in a timely manner for surveyor review, c. The log will contain the name of the individual who comes to the ED seeking treatment, and whether the individual: 1. Refused treatment; 2. Was denied treatment, 3. Was transferred; 4. Was admitted and treated, 5. Was stabilized and transferred; or 6. Discharged; d. The central log is to be retained for EMTALA purposes for a minimum of five years.".

The hospital failed to ensure all patients seeking emergency services were entered onto the ED log (Refer to A2405).


2. Review of a hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)" updated 01/22 revealed, "Medical Screening Examination (MSE), ...1. An appropriate MSE will be provided to every patient who presents to the ED for treatment or is on the campus and requesting emergency treatment to determine whether an EMC exists."

The hospital failed to ensure all patients seeking emergency medical services received a Medical Screening Exam (MSE) (Refer to A2406).


3. Review of hospital policy titled "Against Medical Advice" revised 01/11/05 revealed, "Have patient sign Release Executed when Patient Leaves Contrary to Doctor's Advice". Nursing documentation needed: "2. Time patient left AMA 3. Mode of transportation 5. Reason patient decided to leave AMA 6. risks associated with leaving AMA, and who explained them to the patient 10. Enter dismissal order in the computer".

The hospital failed to ensure all patients received stabilizing treatment and patient's who refuse stabilizing treatment after seeking emergency services, sign that they have been informed of the medical risks leaving without medical care, and still want to leave Against Medical Advice (AMA) (Refer to A2407).


4. Review of a hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)" updated 01/2022 revealed, "Appropriate transfer is one in which all of the following conditions are satisfied 1. The transferring hospital provides medical treatment within the capabilities of its ED to minimize the risks to the health of the individual or unborn child, 2. The receiving facility has available space and qualified personnel to treat the individual and has agreed to accept the transfer of the individual and provide appropriate treatment; 3. The transferring hospital sends the receiving facility all available medical records, or copies, which relates to the individual's EMC (emergency medical condition); 4. The transfer is made with qualified personnel and transportation equipment in an appropriate medical transfer vehicle. Transfers to Another Acute Care Facility; 1. Transfers to other acute care facilities are made after medical evaluation and stabilization of a patient with an EMC, a. A patient with an EMC may be transferred before the condition is stabilized if: 1. The transfer is authorized in writing by the patient or by a legally responsible person acting on the patient's behalf or a physician certification; The patient (or the person acting on the patient's behalf) is informed of the risks of transfer and the hospital's obligations and executes the authorization; or A physician signs a certification that the benefits of transfer outweigh the risks; 2. The patient's physician orders the transfer. The physician completes the Patient Transfer Order form, Once the transfer arrangements have been confirmed, a call to the receiving facility must be done to ensuring that it knows the patient is coming; 4. The above call should be documented on the discharge summary along with the name of the person report was given to at the receiving facility."

Review of the EDs "Transfer Form" revealed, the patient or patient's representative, and physician sign the form agreeing to or declining transfer as deemed appropriate by the medical provider. The transfer forms states "I hereby certify that based upon the information available to me at the time of transfer, the medical benefit reasonably expected from the provision of appropriate medical care at another facility outweighs the increased risk to the individual, and in the case of labor, to the unborn child, from effecting the transfer. There is a section blank titled "risks" and one titled "benefits" that require the physician to document the risks and benefits as discussed with the patient or the patient's representative. Additional information to be added to the transfer form is the name of the physician and the name of the accepting (receiving hospital) as well as the mode of transfer including any additional medical needs.

The hospital failed to ensure all patients had an appropriate transfer and that the transfer documentation explaining the risks and benefits to the transfer were documented (Refer to A2409).

Based on review of hospital policy, emergency department (ED) log, and staff interview, the facility failed to maintain an ED log that accurately documented all patients that sought care and the disposition of the patients. Review of the ED log showed one of 18 patients (Patient 1) was not documented in the ED log. This failure had the potential to affect any individual presenting to the ED seeking assistance.


Findings Include:

Review of the Statement from the Emergency Medical Service (EMS) regarding the events which occurred on 1/10/22 involving Patient 1 showed, when the EMS crew called report into this hospital for Patient 1, they were told by a nurse, Registered Nurse (RN) 3, that they should take the patient to an out of state hospital because they cannot do dialysis here. EMS arrived at this hospital at 3:30 AM and a nurse, RN 1, from this facility came out of the ambulance entrance of the Emergency Room (ER) and told this EMS crew that the facility will not accept this patient as they have no dialysis available. EMS personnel then requested to speak to the ER physician and were told that EMS cannot speak to the ER physician (ED MD 3) while repeating that the patient will not be accepted at this facility and that the hospital was on diversion. EMS personnel then contacted an ER facility located 18 miles away within the state and are advised by the secondary facility that it is an ER only and that they will accept the patient. This EMS crew then transported Patient 1 to the secondary facility without incident.

Review of the ED log for the month of January 2022 revealed, Patient 1 was not included on the ED log on 01/10/22.

During an interview on 02/14/22 at 9:10 AM, Director of Quality Improvement, Risk Management & Compliance (DQIRMC) confirmed Patient 1 was not on the ED log and no record had been generated on behalf of Patient 1 that would define Patient 1's chief complaint for seeking emergency medical treatment.

During a telephone interview on 02/15/22 at 4:41 PM, ED RN 1 stated the ambulance call was taken by another RN (RN 3), but she was aware the ambulance was transporting Patient 1 to their ED and Patient 1 was a dialysis patient. The ED physician felt the patient would be better served at another hospital (Hosp) E. RN 1 confirmed the ambulance did show up onsite at this hospital. RN 1 stated "I went out to the ambulance and told them to take [Patient 1] to [Hosp E] ED" where they could provide dialysis for Patient 1. RN 1 stated "at the time I did that, I was not aware, I couldn't." RN 1 stated, we get EMTALA training annually, but I do not remember discussing being on hospital property obligated the hospital to see the patient.

During a telephone interview on 02/16/22 at 6:30 AM, RN 3 stated, "I talked to the ambulance" while it was enroute to the hospital ED on 01/10/22 transporting Patient 1. RN 3 stated the ambulance was 15-20 minutes out with Patient 1. RN 3 said she was informed that Patient 1 had been in a hospital a week ago, dialysis was due tomorrow, vital signs (VS) were stable, and Patient 1 would likely need dialysis. RN 3 then talked to the ED physician who felt Patient 1 would be better served at [Hosp) E] where they provide dialysis services. RN 3 stated the ambulance staff relayed, per the ambulance service policy, the ambulance does not cross state lines, and Hosp-E was across state line, and the ambulance could not take Patient 1 to Hosp-E. RN 3 stated by the time they ended the call; the ambulance was in town by the Walmart (10 minutes) and did bring the patient but the patient never left the ambulance. The ambulance then transported Patient 1 to Hosp-C.

Based on review of hospital policy, medical record, and staff interview, the facility failed to ensure two of 20 emergency department (ED) patients (Patient 1 and Patient 2) received a Medical Screening Exam (MSE) to rule out an emergency medical condition (EMC). This failure has the potential to miss or delay care for patients seeking emergency medical treatment.


Findings Include:


1. Review of a written statement from the Emergency Medical Service (EMS) crew regarding the events which occurred on 1/10/22 involving Patient 1 showed, when the EMS crew called report into this hospital for Patient 1, they were told by a nurse, ED Registered Nurse (RN) 3, that they should take the patient to an out of state hospital because they cannot do dialysis here. EMS arrived at this hospital at 3:30 AM and a nurse, ED RN 1, from this facility came out of the ambulance entrance of the ED and told this EMS crew that the facility will not accept this patient as they have no dialysis available. EMS personnel then requested to speak to the ED physician and were told that EMS cannot speak to the physician (ED MD 3) while repeating that the patient will not be accepted at this facility and that the hospital was on diversion. EMS personnel then contacted an ED facility located 18 miles away within the state and were advised by the secondary facility that it is an ED only and that they will accept the patient. This EMS crew then transported Patient 1 to the secondary facility without incident.

Review of the ED log for the month of January 2022 revealed Patient 1 was not included on the list of ED patients who sought emergency medical care on 01/10/22.

During an interview on 02/14/22 at 9:10 AM, the Director of Quality Improvement, Risk Management & Compliance (DQIRMC) confirmed there is no medical record documentation for Patient 1 and the hospital failed to provide an MSE for Patient 1 on 01/10/22 per hospital policy.

During a telephone interview on 02/15/22 at 4:41 PM, ED RN 1 stated, on 01/10/22 when Patient 1 showed up onsite in an ambulance, he/she was not aware that the hospital was obligated to conduct an MSE, "I know now".

During a telephone interview on 02/16/22 at 6:30 AM, ED RN 3 stated that when Patient 1 came on the grounds of the hospital by ambulance on 01/10/22, she was not aware the hospital was obligated to conduct an MSE.


2. Review of Patient 2's medical record revealed Patient 2 was a minor brought to this ED on 01/26/22 at 2:08 AM by Family Member (F) 1 and a police escort. Review of a nurse's note written by ED RN 2 on 01/26/22 at 2:13 AM showed, Police Officer came into the ED to request a medical screening exam and COVID testing for Patient 2. She told this nurse and the house supervisor that the community mental health center (CMHC) staff had already arranged for bed placement for Patient 2 but he needs medical clearance including a COVID test before he can go. This nurse informed the Officer that they do not have any rapid COVID swabs and the lab staff are not trained to run the PCR test (polymerase chain reaction - a fast, highly accurate way to diagnose certain infectious diseases). This nurse then called Hospital C's Remote ED to inquire about their COVID tests availability. Hospital C's remote ED RN stated they do have a few on hand and if he needed testing we could send him that way after we were done screening him. She also asked about how would it work with billing since it wasn't an actual ED visit, it would just be solely for the test. The Officer then requested this nurse speak to the staff from the CMHC to inform her of what is going on. CMHC Staff said she would rather just send F 1 and Patient 2 to Hospital C's Remote ED for both the medical screening and COVID test. This nurse and RN 4 then went to speak to the mother about the option of having the patient medically screened here and wait for COVID test result when we were able to get the test done or medically screen here then send to Hospital C's Remote ED for a COVID test, or they could have the option of doing both the screening and test done at Hospital C's Remote ED. F 1 chose to have both done at Hospital C's Remote ED and stated she did not want to risk losing the bed waiting on the COVID test. So, F 1 and Patient 2 headed to Hospital C's Remote ED location. The medical record lacked documentation of any medical screening exam.

Review of the document titled, "Refusal of Medical Screening Exam," signed by ED RN 2 and RN 4, Night House Supervisor at 01/26/22 at 1:00 AM showed, F 1 and staff from the CMHC requested patient be seen at Hospital C's Remote ED to have the medical screening and the COVID testing completed at one facility since this hospital does not have the rapid COVID testing and PCR testing can't be run at night due to untrained lab personnel. The CMHC staff voiced concern about losing bed placement for Patient 2 if they had to wait 12 -24 hours for the results of a PCR test.

During a telephone interview on 02/14/22 at 1:41 PM, F 1 stated, Patient 2 was "being admitted to juvenile mental health facility because [Patient 2] was violent, and I was afraid." F 1 said the police talked to an RN (ED RN 2) at this hospital but that the RN never spoke to her. F 1 confirmed that he/she was given the address of Hospital C's Remote ED location to take Patient 2 for the medical screen and COVID testing.

During a telephone interview on 02/14/22 at 4:41 PM, ED RN 2 confirmed Patient 2 did not receive an MSE on 01/26/22 when Patient 2 came to the ED. RN 2 stated at the time this occurred, "I was not aware we could not send the patient to another ED without performing an MSE".

During a telephone interview on 02/14/22 at 7:36 PM, RN 4, Night House Supervisor stated on 01/26/22, "I was in ER the entire time, and Patient 2 and Family (F)1 were given a choice to go to Hospital (Hosp)- C's ED. "Yes, I know now, the patient needed to be screened (MSE)".

Based on review of medical record review, policy review, and staff interview, the facility failed to ensure two of three patients (Patient 8 and 9) were provided stabilizing treatment prior to discharge or transfer and failed ensure one of three patient (Patient 9) signed an Against Medical Advice (AMA) form prior to leaving the Emergency Department (ED). Failure to provide stabilizing treatment and inform patients of the risk and benefits of leaving AMA places them at risk for deterioration of their emergency medical condition.


Findings Include:

Patient 8

Review of Patient 8's medical record revealed Patient 8 was logged into the ED on 02/06/22 at 7:39 PM. Review of the Emergency Department Note History of Present showed Patient 8 was an 11-year-old male who presented for evaluation of acute right-sided testicular pain while bathing earlier in the day. Patient 8 reported similar pain the week prior that spontaneously resolved. The exam narrative showed both testicles were tender, with the right being more tender then the left. Patient 8 was transferred to a children's hospital (Hosp)-D for formal ultrasound and pediatric urology consultation.

Further review of Patient 8's medical record revealed there was no pain scale assessment to determine the extent of Patient 8's pain and no pain medications were provided to stabilize Patient 8's pain prior to transferring to Hospital D.


Patient 9

A review of Patient 9's medical record showed the following documentation for 01/27/22:

An ED medical record triage note revealed Patient 9 sought emergency medical treatment on 01/27/22 at 1:17 PM. Chief complaint is documented as "Altered Mental Status."

A physician's narrative note revealed, "42-year-old brought in by EMS [emergency medical services], altered mental status, fall from bed on the floor. Did strike his head, unknown about loss of consciousness, he is very somnolent does not answer any questions. Well known to our facility by frequent visits regarding his diabetes, which is poorly controlled, end stage renal disease on dialysis Monday Wednesday Friday, missed yesterday, frequently here for cyclic vomiting related to his cannabis abuse, also has gastroparesis related diabetes. Is vomiting on arrival here, was found lying beside his bed, has contusion of the forehead, has no other complaints but is not answering any questions. Blood sugar was elevated according to home health, was 490 before getting insulin, on arrival here is 400.

[Patient 9] did have a brief tonic-clonic seizure on arrival here, and later his family member arrived and stated that this is a new occurrence and that he had a seizure earlier today which is why they called 911, though this was not mentioned by EMS."

A physician note titled, "Altered Status Narrative: Patient arrives stable and nontoxic on exam, very somnolent but no focal neurologic deficits. He is having some vomiting here; this is chronic and very typical for patient's presentation to the ER. He was given antiemetics with improvement and resolution of vomiting. He also has a cough, active COVID-19 infection, no hypoxemia, vital signs otherwise stable. He does have hypertension here, consistent with fluid overload and end-stage renal disease on dialysis, has missed yesterday session, I gave hydralazine for blood pressure with improvement. His chest x-ray is consistent with fluid overload and multilobar infection consistent with COVID."


A vital sign flow sheet revealed: Blood Pressure (BP) right arm; at 2:19 PM 217/116 H (high), at 2:20 PM BP 218/103 H, at 2:30 PM BP 198/86 H, at 2:45 PM BP 193/97 H, at 3:00 PM BP 197/93 H and at 3:15 PM BP 192/92 H.

Review of the medical decision making (MDM) section of the Emergency Department Note showed, "Patient did have brief tonic-clonic seizure, recovered well with no prolonged postictal phase. ... I had a long talk with him and his family member about our limitations of ability to provide care for his end-stage renal disease. ... After discussion with him he will leave AMA to follow up with his dialysis center, understands return here if he has any worsening symptoms or stroke-like symptoms, recurrent seizures.

There was no evidence in the medical record to show that attempts were made to transfer Patient 9 to a facility who had the ability to provide care for his end-stage renal disease.

A physician note documented: Patient Disposition: Left Against Medical Advice.

Nursing documentation under "Disposition" showed "discharge."

During a telephone interview 02/16/22 at 6:22 AM, ED MD 1 stated, "we were in the peak of COVID at that time and it was difficult to find an open bed. I wanted Patient 9 to wait for a transfer, I was able to get Patient 9's BP under control, but blood sugar was still high, and Patient 9 needed dialysis for the fluid overload. Patient 9 did have a seizure while in the ED. Patient 9 needed additional monitoring and care. Patient 9 and a significant other refused to stay and wait for a bed to open up but were willing to review the risks for leaving AMA. I also provided Patient 9 with information on fluid overload and COVID."

Review of Patient 9's medical record failed to show a signed AMA form, documentation from ED MD 1 that he provided any of the risks for leaving AMA, and information on fluid overload or for COVID.

Further review of Patient 9's medical record showed that Patient 9's family member (F) 9 signed discharge instructions provided by nursing staff including documents regarding Cyclic Vomiting Syndrome, Dialysis Diet, and Hemodialysis for Acute Kidney Failure. The discharge instructions lacked evidence Patient 9 was provided instruction or information related to the new onset of seizures or altered mental status.


During an interview at the same time as the record review for Patient 9 on 2/15/22 at 10:29 AM, the Director of Quality Improvement, Risk Management & Compliance and (DQIRMC) and Emergency Department Manager (EDM), the EDM confirmed the AMA document is not in the medical record and the nurses should have completed the AMA paperwork and not discharge paperwork.

Based on policy review, medical record review, and interviews, the facility failed to ensure, 1. two of seven patients (Patient 8 and Patient 14) transferred had the risks and benefits of the transfer documented in the medical record and 2. the facility failed to ensure one patient (Patient 2), with mental health concerns and recent aggressive behavior, was transferred through qualified personnel. These failures had the potential to affect all patients presenting to the emergency department (ED) and who subsequently required an appropriate transfer to another facility.


Findings Include:


1. Review of Patient 8's medical record revealed Patient 8 was logged into the ED on 02/06/22 at 7:39 PM, he was 11 years old. Chief complaint was listed as right testicle pain and swelling. Documentation revealed that the ED physician wanted Patient 8 to be seen at the children's hospital (Hosp)-D.

Further review of Patient 8's medical record revealed there was no risks and benefits of the transfer documented in the medical record. The medical record revealed there was no pain assessment and no pain medication provided to Patient 8 to minimize risks during transfer to Hospital D.


Review of Patient 14's ED medical record revealed, Patient 14 arrived at the ED on 01/19/22 at 10:07 PM. Chief complaint was Acute psychosis-hearing voices. Documentation revealed that the ED Physician wanted Patient 14 to be transferred to Hosp-B.

Further review of Patient 14's medical record revealed there was no risks and benefits of the transfer documented in the medical record.

During an interview of on 02/15/22 at 1:30 PM after completed medical record reviews for Patient 8 and Patient 14, Emergency Room Manager (EDM) confirmed, the transfer forms were not documented for Patient 8 on 02/06/22, or Patient 14's on 01/19/22, and they should have been in the medical record.



2. Review of Patient 2's medical record revealed Patient 2 was a minor brought to this ED on 01/26/22 at 2:08 AM by Family Member (F) 1 and a police escort. Review of a nurse's note written by ED RN 2 on 01/26/22 at 2:13 AM showed, Police Officer came into the ED to request a medical screening Patient 2. She told this nurse and the house supervisor that the community mental health center (CMHC) staff had already arranged for bed placement for Patient 2 but he needs medical clearance including a COVID test before he can go. This nurse informed the Officer that they do not have any rapid COVID swabs and the lab staff are not trained to run the PCR test (polymerase chain reaction - a fast, highly accurate way to diagnose certain infectious diseases). This nurse then called Hospital C's Remote ED to inquire about their COVID tests availability. Hospital C's remote ED RN stated they do have a few on hand and if he needed testing, we could send him that way after we were done screening him. She also asked about how it would work with billing since it wasn't an actual ED visit, it would just be solely for the test. The Officer then requested this nurse speak to the staff from the CMHC to inform her of what is going on. CMHC Staff said she would rather just send F 1 and Patient 2 to Hospital C's Remote ED for both the medical screening and COVID test. This nurse and RN 4 then went to speak to the mother about the option of having the patient medically screened here and wait for COVID test result when we were able to get the test done or medically screen here then send to Hospital C's Remote ED for a COVID test, or they could have the option of doing both the screening and test done at Hospital C's Remote ED. F 1 chose to have both done at Hospital C's Remote ED and stated she did not want to risk losing the bed waiting on the COVID test. So, F 1 and Patient 2 headed to Hospital C's Remote ED location. No transfer document was found in Patient 2's medical record.

Review of the document titled, "Refusal of Medical Screening Exam," signed by ED RN 2 and RN 4, Night House Supervisor at 01/26/22 at 1:00 AM showed, F 1 and staff from the CMHC requested patient be seen at Hospital C's Remote ED to have the medical screening and the COVID testing completed at one facility since this hospital does not have the rapid COVID testing and PCR testing can't be run at night due to untrained lab personnel. The CMHC staff voiced concern about losing bed placement for Patient 2 if they had to wait 12 -24 hours for the results of a PCR test.

During a telephone interview on 02/14/22 at 1:41 PM, F 1 stated, Patient 2 was "being admitted to juvenile mental health facility because [Patient 2] was violent, and I was afraid." F 1 said the police talked to an RN (ED RN 2) at this hospital but that the RN never spoke to her. F 1 confirmed that he/she was given the address of Hospital C's Remote ED location to take Patient 2 for the medical screen and COVID testing.

During a telephone interview on 02/14/22 at 4:41 PM, ED RN 2 stated she did not complete transfer paperwork for Patient 2, stating F 1 took Patient 2 to the other hospital in their personal vehicle. RN 2 confirmed she did not know if F 1 and Patient 2 had a police escort.

During a telephone interview on 02/14/22 at 7:36 PM, RN 4, Night House Supervisor on 01/26/22, when asked if Patient 2 had an appropriate transfer with qualified personnel, she stated that she thought the police would escort Patient 2 and F 1 but she understands that didn't happen.