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Based on review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) related policy, Medical Staff Bylaws and Rules and Regulations, Emergency Department (ED) medical records (MR), Nurse Practitioner (NP) credentialing files, and interviews with staff it was determined Flowers Hospital (Hospital # 1) was not in compliance with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases.

Findings include:

1. The facility failed to maintain an ED central log with the accurate disposition of each patient who presented to the ED for assessment/evaluation.

Refer to Tag 2405

2. The facility Board of Trustees failed to identify and approve the Nurse Practitioner as qualified to conduct medical screening examinations in the Emergency Department.

Refer to Tag 2406

3. Hospital # 1 failed to arrange an appropriate transfer of Patient Identifier (PI) # 16 to Southeast Health (Hospital # 2).

Refer to Tag 2409

Based on review of the facility's policy, Emergency Department (ED) central logs, ED medical records and interview with facility staff, it was determined the facility failed to maintain an ED central log with the accurate disposition of each patient who presented to the ED for assessment/evaluation.

This deficient practice affected 1 of 22 sampled ED records reviewed, including Patient Identifier (PI) # 16.

Findings include:

Policy: Emergency Medical Treatment and Patient Transfer Policy
Revised: 9/1/13

Introduction: The purpose of this policy is to...provide an overview of the Emergency Medical Treatment and Labor Act (EMTALA)...

Definitions:
...Central Log means a log the hospital maintains of all individuals who present to the hospital seeking emergency medical assistance and the disposition of such individuals, whether the person... was transferred...or discharged. The purpose of the Central Log is to track the care provided to each individual who comes to the Hospital seeking care for an Emergency Medical Condition...

A. General

...6. Emergency Department Log. The Hospital shall maintain a Central Log on each individual who comes to the Emergency Department (ED) seeking assistance and indicate whether the individual...was transferred...or discharged.


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PI # 16 presented to the ED on 7/9/19 at 8:38 PM with his/her mother, who stated the patient was not acting like himself/herself and had been verbally threatening mother.

Review of PI # 16's ED medical record revealed PI # 16 was evaluated and treated by the ED physician with Impression and Plan as:

Diagnosis: Hallucinations, Psychosis and Homicidal Ideations
Plan: Transfer Patient (order) dated 7/10/19 at 1:17 AM to Behavioral Health, waiting on Mental Health Officer for transport to BMU (Behavioral Mental/Health Unit).

Review of the ED Disposition Summary revealed:

Transfer to (name of hospital)
ED Transfer reason: Psychiatrics - Specialized Care
Departure Time 7/10/19 at 2:08 AM
Discharged in care of HCSO (Houston County Sheriff Office) for transport.

Review of the ED Central Log dated 7/9/19 revealed the disposition of PI # 16 was D/C (discharge) Home. There was no documentation on the log indicating PI # 16 was transferred to another facility for inpatient care.

An interview conducted 7/17/19 at 9:15 AM with Employee Identifier # 1, Assistant Chief Nursing Officer and Acting Emergency Department Director, confirmed the ED log was inaccurate and should have identified PI # 16 as a Hospital Transfer.

Based on review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) related policy, Medical Staff Bylaws and Rules and Regulations, medical records (MR), Nurse Practitioner (NP) credentialing files, and interviews with leadership staff it was determined the facility Board of Turstees failed to identify and approve the Nurse Practitioner as qualified to conduct medical screening examinations in the Emergency Department (ED).

This deficient practice affected 4 of 22 ED records reviewed, including Patient Identifier (PI) # 8, PI # 9, PI #5, PI # 12.

Findings include:

Policy: Emergency Medical Treatment and Patient Transfer Policy
Revised: 9/1/13

Introduction: The purpose of this policy is to...provide an overview of the Emergency Medical Treatment and Labor Act (EMTALA)...

Definitions: For the purpose of this EMTALA Policy, the following terms are defined as follows:

...Qualified Medical Personnel refers to those individuals defined by the Hospital's Medical Staff Bylaws, Rules and Regulations and approved by the Hospital's governing board to perform the initial Medical Screening Examinations for those individuals who come to the dedicated ED and request examination or treatment.

...I. Medical Screening Examination

A. General

1. Medical Screening... Medical Screening Examinations shall be performed by an ED physician or another licensed practitioner as appointed and approved by the Hospital's Medical Staff and Board of Trustees (if the Medical Staff or Board of Trustees determines that a licensed practitioner other than an Emergency Department Physician may perform screening exams...)

1. PI # 8 presented to the ED on 4/4/19 at 12:51 PM with a Closed Head Injury without Loss of Consciousness and Closed Depression Fracture of the Skull.

Review of the MR documentation dated 4/4/19 at 12:55 PM revealed the medical screening examination (MSE) was conducted by a NP and not an ED Physician.

2. PI # 9 presented to the ED on 4/8/19 at 12:32 PM with Abdominal Pain and Suicidal Thoughts.

Review of the MR documentation dated 4/8/19 at 5:43 PM revealed the MSE was conducted by a NP and not an ED physician.

3. PI # 5 presented to the ED on 7/5/19 at 12:57 PM with Pregnancy and Abdominal Pain.

Review of the MR documentation dated 7/5/19 at 2:28 PM revealed the MSE was conducted by a NP and not an ED physician.

4. PI #12 presented to the ED on 7/12/2019 at 8:39 AM with Suicide Attempt.

Reviewof the MR documentation revealed the MSE was conducted at 9:15 AM by a NP not an ED physician.

Review of the facility's Medical Staff Bylaws and Rules and Regulations revealed the Board of Trustees failed to designate and approve Nurse Practitioners as qualified to perform the initial Medical Screening Examination for Individuals seeking care in the Emergency Department.

Review of the credentialing files for the NP's who conducted the MSE's Listed above, revealed the Core Privileges did not include conducting medical screening examinations for ED patients.

An interview was conducted 7/17/19 at 10:00 Am with Employee Identifier #2, Chief Quality Officer , confirmed the Medical Staff Bylaws and the NP credentialing Core Privileges did not identify NPs as qualified by the Medical Staff to conduct the MSE for ED patients.


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4. PI # 11 presented to the ED on 7/14/19 at 1:48 PM with complaints of being "scared and worried" and had a discharge diagnosis of Depression.

Review of the MR documentation revealed the MSE was conducted at 2:22 PM by a NP and not an ED physician.

5. PI # 12 presented to the ED on 7/12/19 at 8:39 AM with Suicidal Ideation.

Review of the MR documentation revealed the MSE was conducted at 9:15 AM by a NP not an ED physician.

6. PI # 22 presented to the ED via ambulance on 3/10/19 at 12:12 PM with Suicide Attempt.

Review of the MR documentation revealed the MSE was conducted at 2:08 PM by a NP not an ED physician.

Review of the facility's Medical Staff Bylaws and Rules and Regulations revealed the Board of Trustees failed to designate and approve Nurse Practitioners as qualified to perform the initial Medical Screening Examination for individuals seeking care in the Emergency Department.

Review of the credentialing files for the NPs who conducted the MSEs listed above, revealed the Core Privileges did not include conducting medical screening examinations for ED patients.

An interview conducted 7/17/19 at 10:00 AM with Employee Identifier # 2, Chief Quality Officer, confirmed the Medical Staff Bylaws and the NP credentialing Core Privileges did not identify NPs as qualified by the Medical Staff to conduct the MSE for ED patients.

Based on review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) related policy, medical records, and interviews, it was determined Flowers Hospital (Hospital # 1) failed to arrange an appropriate transfer of Patient Identifier (PI) # 16 to Southeast Health (Hospital # 2) by failing to:

1. Contact the receiving hospital for bed availability.

2. Obtain receiving physician's acceptance.

3. Provide medical records and a verbal report to Hospital # 2 regarding PI # 16's Emergency Medical Condition and treatment provided in the Emergency Department (ED).

This affected 1 of 15 transfer records reviewed and had the potential to affect all patient's transferred from the ED.

Findings include:

Policy: Emergency Medical Treatment and Patient Transfer Policy
Revised: 9/1/13

Introduction: The purpose of this policy is to...provide an overview of the Emergency medical Treatment and Labor Act (EMTALA)...

Definitions: For the purpose of this EMTALA Policy, the following terms are defined as follows:

...Appropriate Transfer occurs when...
2. the receiving facility has the appropriate 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.
3. the transferring hospital sends to the receiving hospital all medical records (or copies thereof) related to the Emergency Medical Condition, including available history, that are available at the time of transfer pertaining to the individual's Emergency Medical Condition...

...II Transfer of Individuals...

D. Transfer Procedures...

1. Acceptance by Receiving Hospital and Receiving Physician. Prior to transfer, the receiving hospital and receiving physician must consent to the transfer of the individual and agree to provide appropriate medical treatment and hospital care.

...4. Personnel and Procedures. The hospital will provide that licensed nurses...are available...to assist with patient transfers, provide accurate information...

...5. Medical Records. If the hospital transfers a patient, the hospital will provide to the receiving physician and receiving hospital a copy of those portions of a patient's MR that are available and relevant to the transfer and to the continuing care of the individual. These records will accompany the patient to the receiving hospital...



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PI # 16 presented to the ED on 7/9/19 at 8:38 PM with his/her mother, who stated the patient was not acting like himself/herself and had been verbally threatening mother.

Review of the MR revealed Medical Decision Making: "Pt was initially cooperative with the first part of the exam. It was clear that the patient requires hospitalization for homicidal ideation as the patient is a danger to others. As we were attempting to sedate him/her he/she became extremely belligerent, ripped out his/her IV and threatened to harm staff in the emergency department. At this point want (?police) force was called and the patient was forcibly placed into a hospital bed with handcuffs. The patient then received 400 mg (milligrams) of Ketamine IM (intramuscular). This sedated him/her sufficiently such that we could take off the handcuffs...then received 2 mg of Ativan and 25 mg of Benadryl IV in addition to the initial Ketamine dose. The Houston County Mental Health Officer assessed the patient and has ordered that he/she be placed in inpatient psychiatric treatment for his/her and the public's safety. The patient will be transferred to an inpatient psychiatric facility after he/she is woken up enough to respond to commands. Patient is medically cleared for inpatient psychiatric treatment..."

Further review of PI # 16's ED medical record revealed Impression and Plan as:

Diagnosis: Hallucinations, Psychosis and Homicidal Ideations
Plan: Transfer Patient (order) dated 7/10/19 at 1:17 AM to Behavioral Health, waiting on Mental Health Officer for transport to BMU (Behavioral Medical Unit).

Review of the ED Disposition Summary revealed:

Transfer to (Hospital # 2)
ED Transfer reason: Psychiatrics - Specialized Care
Departure Time 7/10/19 at 2:08 AM
Discharged in care of HCSO (Houston County Sheriff Office) for transport.

There was no transfer form, no documentation in the MR that Hospital # 2 was contacted to verify bed availability and agreement to accept PI # 16; no documentation of a receiving physician acceptance and no documentation Hospital # 1 provided copies of the MR or gave a verbal report to Hospital # 2.

Interviews

An interview was conducted on 7/17/19 at 8:15 AM with Employee Identifier (EI) # 1, Assistant Chief Nursing Officer and Acting ED Director, to determine the facility's transfer practices and role of the Mental Health Officer (MHO) in the ED. EI # 1 stated in 2017 the county provided a training program to train MHO's who could evaluate psychiatric patients that were a danger to self or other and place a hold on the patient so they can be admitted for care. EI # 1 stated seven hospital employees, including himself, were trained MHOs.

EI # 1 was asked to describe what he knew about the care of PI # 16 on 7/9/19. EI # 1 stated the MHO involved with PI # 16 was a police officer not a hospital employee, therefore did not know about EMTALA regulations. EI # 1 stated the transfer of PI # 16 "should have occurred just like any other transfer." Further, EI # 1 confirmed there was no physician to physician contact to confirm acceptance of PI # 16 and no documentation anyone called Hospital # 2 to obtain acceptance of the transfer.

An interview was conducted on 7/17/19 at 10:28 AM with EI # 3, Clinical Supervisor ED, to determine the ED process for patient transfers. EI # 3 stated the physician would let the staff know what services were needed and the Charge Nurse or Case Management would make the initial phone call to facilitate the physician to physician communication. Then the Charge Nurse would initiate the transfer form, make copies of the chart and the completed transfer form. One copy of the transfer form would be sent with the patient along with copies of the record.

An interview was conducted on 7/17/19 at 11:00 AM with MD # 1, the ED Physician that treated PI # 16. MD # 1 confirmed he/she did not contact anyone at the receiving hospital. MD # 1 stated he/she was informed by the MHO the patient needed to be ambulatory before he (MHO) took (PI # 16) to BMU (Behavioral Medical Unit -Southeast Health). MD # 1 stated after a couple of hours the sedation wore off and PI # 16 was able to ambulate to the police cruiser for transport. MD # 1 stated "I assumed the MHO took care of contacting the other hospital."

An interview was conducted on 7/18/19 at 8:31 AM with EI # 4, Clinical Supervisor ED, who was on duty when PI # 16 was discharged from the ER.

EI # 4 stated when the physician determined PI # 16 was a risk to become violent, the police were called. Two police officers arrived in the ED. PI # 16 pulled the IV (intravenous) line out and was bleeding, saying he/she was going to kill his/her mother and staff. EI # 4 stated he notified MD # 1 that there was no hospital MHO on duty. The police officers informed EI # 4 they had a MHO on duty that could be contacted. The MHO arrived and asked if the patient needed to be admitted and EI # 4 responded "yes". The MHO stated he had called BMU and they were not on diversion. The MHO stated "typically we take all of our cases there." The surveyor showed EI # 4 the transfer order written by the physician on 7/10/19 at 1:15 AM and asked why the hospital transfer process was not followed? EI # 4 stated he did not see the transfer order. EI # 4 stated the MHO said "I will take care of (PI # 16) when you discharge him/her." EI # 4 stated "my understanding was we discharge him/her to the deputy and they take him/her."

Hospital # 1 failed to complete an appropriate transfer of PI # 16 to Hospital # 2 as directed by the facility policy.