HospitalInspections.org

Based on a review of documentation and interviews with staff, the hospital failed to comply with §489.24, as they failed to provide an appropriate medical screening exam, stabilizing treatment or an appropriate transfer (as cited under §489.24(a), §489.24(c), §489.24 (d)(1), (2) and (3) and §489.24(e)(1) and (2).

The above was confirmed in an interview with the CEO, the QM/Compliance Director and the Crisis Director on the afternoon of 4-18-18.

Based on a tour of the facility and an interview with staff, the failed to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX.

Findings were:

During a tour of the facility with staff #4 on 4-18-18, no EMTALA/medical screening exam signage was noted either in the lobby or in the foyer entrance to the lobby. Outside the lobby doors was signage (printed on the glass) that stated "Crisis Services & Extended Observation Unit - after normal hours, press for assistance". In an interview with staff #4 at the time of the tour, staff #4 stated that the intercom button connects the person with the nurse's station in the Emergency Outpatient Unit. Staff #4 stated that the nurse lets an MCOT (mobile crisis outreach team) member (located inside the building at all times) know that someone in crisis is outside the door and the member goes and gets the patient, brings them inside and talks to them.

Staff #4 stated that the intake screening is done in a hallway that is not considered part of the hospital and is prior to the double doors that signify the start of the hospital. He also stated that the hallway in which the screening takes place is not part of the emergency outpatient unit or the outpatient clinic, either.

The above was confirmed in an interview with the CEO, the QM/Compliance Director and the Crisis Director on the afternoon of 4-18-18.

Based on a review of documentation and interviews with staff, the hospital failed to maintain medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer.

Findings were:

In an interview with staff #4 on 4-18-18, staff #4 stated that no separate record was kept of individuals transferred to or from the hospital and no such record was available for the surveyor's review.

The above was confirmed in an interview with the CEO, the QM/Compliance Director and the Crisis Director on the afternoon of 4-18-18.

Based on a review of facility documentation and an interview with staff, the hospital failed to maintain a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition.

Findings were:

A review was conducted of the document titled "Sunrise Canyon Hospital - After Hours On-Call Physician Schedule" for the dates of January 2017 through December 2017. Each day of each month stated "[staff #16]" or "[telemedicine physician contracted service name]". On the days of the month covered by a contracted physician, there was no individual physician's name noted; only the name of the contracted service.

The above was confirmed in an interview with the CEO, the QM/Compliance Director and the Crisis Director on the afternoon of 4-18-18.

Based on a review of documentation and an interview with staff, the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction.

Findings were:

During a review of 13 crisis assessments, 8 of the individuals on whom assessments had been performed (patients #2, #3, #5, #6, #8, #9, #11 and #13) had presented to the facility for treatment. 8 of the 8 patients failed to receive an appropriate medical screening exam.

A review of facility policies and procedures revealed no policies pertaining to EMTALA or to the performance of a medical screening exam.

In an interview with staff #1 on 4-18-18, staff #1 confirmed that the facility had no policies or procedures related to EMTALA or the performance of a medical screening exam.

A review of facility Bylaws, Rules and Regulations of the Medical Staff revealed the following:
Page 15
"Section 3. Medical Director
The Medical Director shall be a member of the medical staff and shall be certified in psychiatry or eligible for certification by the American board of Psychiatry and Neurology and whose duties shall include, but not be limited to the following:
...
(l) ensure that all patients receive appropriate evaluation, diagnosis, treatment, medical screening and medical/psychiatric evaluation whenever indicated, and that all medical/psychiatric care is appropriately documented in the medical record."
The Bylaws, Rules & Regulations did not designate any individuals that were considered qualified to perform the medical screening exam.

The above was confirmed in an interview with the CEO, the QM/Compliance Director and the Crisis Director on the afternoon of 4-18-18.

Based on a review of documentation and interviews with staff, the facility failed to provide stabilizing treatment to individuals presenting to the facility that were determined to have an emergency medical condition.

Findings were:

During a review of 13 crisis assessments, 8 of the individuals on whom assessments had been performed (patients #2, #3, #5, #6, #8, #9, #11 and #13) had presented to the facility for treatment. 2 of the 8 patients (patients #3 and #6) had been determined to have an emergency medical condition requiring transfer of the patient to a higher level of care. There was no documentation that stabilizing treatment had been provided.

A review of facility policies and procedures revealed no policies pertaining to EMTALA.

In an interview with staff #1 on 4-18-18, staff #1 confirmed that the facility had no policies or procedures related to EMTALA.

In an interview with staff #4 on 4-18-18, staff #4 was asked if the facility provided any stabilizing treatment to individuals deemed to have an emergency medical condition. Staff #4 stated "We just call 911".

The above was confirmed in an interview with the CEO, the QM/Compliance Director and the Crisis Director on the afternoon of 4-18-18.

Based on a review of documentation and an interview with staff, the facility failed to transfer appropriately those individuals determined to have an emergency medical condition.

Findings were:

During a review of 13 crisis assessments, 8 of the individuals on whom assessments had been performed (patients #2, #3, #5, #6, #8, #9, #11 and #13) had presented to the facility for treatment. 2 of the 8 patients (patients #3 and #6) had been determined to have an emergency medical condition requiring transfer of the patient to a higher level of care and had been transported by EMS to the higher level of care. There was no documentation that the individuals had requested the transfer after being informed of the hospital's obligations and of the risk of transfer. There was also no written request for transfer, indicating the reasons for the request or that the individual was aware of the risks or benefits of the transfer.

A review of facility policies and procedures revealed no policies pertaining to EMTALA.

In an interview with staff #1 on 4-18-18, staff #1 confirmed that the facility had no policies or procedures related to EMTALA.

The above was confirmed in an interview with the CEO, the QM/Compliance Director and the Crisis Director on the afternoon of 4-18-18.