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Based on policy review, document review, medical record review, and interview, the facility failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA). This failure potentially placed all patients at increased risk for adverse outcomes.

Findings #1 include:

Document review from 12/12/23 to 12/14/23 at Strong Memorial Hospital West Brockport revealed no evidence of a policy that encompasses all the Emergency Medical Treatment and Active Labor Act (EMTALA) requirements and regulations. Specifically, there is no policy related to the following EMTALA requirements:
-The transfer utilizes qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer.
-If a physician is not physically present in the emergency department at the time of a patient transfer, the physician assistant can sign the transfer certification after consultation with a physician who agrees with the certification and subsequently co-signs the certification.
-The patient or patient representative requests (consent to) the transfer, after being informed of the hospital's obligations and of the risk of transfer. The request must be in writing.

Interview on 12/14/23 at 02:21 PM with Staff (B), Assistant Director of Nursing, Quality and Patient Safety Outcomes at Strong Memorial Hospital West Brockport emergency department confirmed the facility does not have an Emergency Medical Treatment and Active Labor Act (EMTALA) policy.

Additional Findings Include:
The hospital failed to ensure that all requirements of an appropriate transfer to another medical facility were met. Specially, Strong Memorial Hospital West Brockport emergency department staff failed document that patients were stable to transfer by personal vehicle for two of four patients (Patient #1 and #10); no evidence was found to indicate the attending physician was consulted and agreed with the physician assistant for the transfer for three of seven patients (Patient #1, #10, and #19). The attending physician also did not co-sign the Acute Patient Transfer Certification; staff did not obtain consent from the patient/patient representative for the transfer to another hospital for 2 of 18 patients (Patients #7, and #8); and staff failed to provide specific risks of transfer based on the medical condition of five of five patients (Patient #1, #7, #8, #10 and #19) (A2409).

Cross Reference:
489.24 (e) (1)-(2) Appropriate Transfer

Based on policy review, medical record review, document review, and interview, the facility failed to ensure that all requirements of an appropriate transfer to another medical facility were met. Specifically, Strong Memorial Hospital West Brockport
- Emergency department staff failed to document that patients were stable to transfer by personal vehicle for two of four patients (Patient #1 and #10) to a higher level of care at another hospital. Instead, personal vehicles were used for the transfers.
- There was no evidence to indicate that the attending physician was consulted and agreed with and co-signed the "Acute Patient Transfer Certification" of the Strong Memorial Hospital West Brockport physician assistant for the transfer of three of seven patients (Patient # 1, #10, and #19).
-Emergency department staff did not obtain patient/patient representative consent to transfer to another hospital for 2 of 18 patients (Patients #7, and #8).
-Emergency department staff failed to provide specific risks of transfer based on the patient's medical condition for five of five patients. (Patient #1, #7, #8, #10, and # 19).
This is evidenced by:
Review of the Strong Memorial Hospital West Brockport policy "Patient Transfer Process," last revised 12/14/21, and "Transfer to Higher Level of Care for Strong West and Urgent Care" last revised 11/13/23, indicated a patient may drive themselves or be driven via private vehicle according to provider discretion. The patient must be accepted by a receiving provider and the same transfer process should be followed. If the provider feels the patient is not stable enough to transfer via private vehicle or if the patient refuses transfer to a higher level of care, the provider may have the patient sign out against medical advice.
The facility does not have an Emergency Medical Treatment and Active Labor Act (EMTALA) policy.
Review of the "Bylaws of the Medical Staff Strong Memorial Hospital of the University of Rochester," last revised 04/06/22, indicated that "dependent allied health professional staff (physician assistants) are not members of the medical staff and may only practice under the supervision of an attending medical staff member per law/regulation or by hospital/department policy in which the supervising physician is credentialed."

Review of the "Acute Patient Transfer" form revealed that staff are to complete all sections of the form. The "Transfer Arrangements" section lists the receiving hospital and name of accepting physician and check off boxes to indicate the receiving hospital has available space, qualified staff, and has agreed to accept the patient. The section has a check off box to indicate the patient has been assessed and will be transferred by qualified personnel and transportation equipment including the use of necessary and medically appropriate life support measure to manage expected risks until the patient is received by the accepting facility. (The form does not document the required mode of transportation (personal car, ambulance) and/or an appropriate level of personnel and equipment (BLS/basic life support, ACLS/advanced cardiac life support) needed to accompany the patient during transfer). The "Transferring Provider's Certification" section has a line for the provider who executed the transfer to sign and date certifying the information listed on the form. (The form does not require co-signature by the attending physician when a physician assistant facilitated the transfer). The "Consent to Transfer" section has check off boxes to indicate if the patient and/or the legally responsible person on behalf of the patient requests, consents to, or refuses transfer, and has been informed of the benefits and risks involved in transfer. There is a line for the patient and a line for the legally responsible person to sign. "The Benefits and Risks of Transfer (Complete A & B)" section lists "expected benefits of transfer include and risks of transfer include: (check one) no significant risk, or worsening of existing condition, please detail.

1. Review of the Strong Memorial Hospital West Brockport emergency department medical record for Patient #1, dated 11/25/23, revealed at 09:46 AM, Patient #1 arrived at the emergency department via car with the complaint of a cough, shortness of breath, chest tightness, and mild dizziness/lightheadedness. At 10:20 AM, Patient #1's blood pressure was 198/88 (normal blood pressure is less than 120/80). At 10:20 AM Staff (U), Physician Assistant assessment indicated "will obtain labs as well as imaging, including ultrasound of the right lower extremity, chest x-ray, and reassess." The chest x-ray results indicated mild pulmonary edema (fluid buildup in the lungs), an ultrasound indicated there was a blood clot in the right leg and the electrocardiogram indicated left atrial enlargement (one chamber of the heart gets bigger than normal), an incomplete left bundle branch block (a partial block of the electrical impulses of the heart), left ventricular hypertrophy with secondary repolarization abnormality (condition where the hearts main pumping chamber thickens and can cause abnormalities on an electrocardiogram), and an anterior ST elevation (an elevation can be caused by a blockage in one of the hearts main blood vessels.) Lab results indicated the following:
-red blood cell count of 3.6 million per microliter (measures the number of red blood cells in your body, normal is 4.35 to 5.65 million per microliter of blood for men)
-hemoglobin of 10.3 grams per deciliter (a protein inside red blood cells that carry oxygen; normal is 13.5 - 17.5 grams per deciliter for men)
-hematocrit of 32% (the amount of whole blood that is made up of red blood cells; normal is 40-50% for men)
-glucose of 137 (sugar in your blood; a normal non-fasting glucose is under 125)
-sodium of 147 (a type of electrolyte/mineral in blood; normal is 135 - 145)
-potassium of 3.2 (a mineral in your blood that helps with heart function; normal is 3.7 - 5.2 milliequivalents per liter)
-chloride of 109 (an electrolyte that reflects your bodies fluid balance; normal is 96 - 106 milliequivalents per liter)
-blood urea nitrogen of 37 (BUN, measures the amount of urea nitrogen - a waste product removed by the kidneys; normal is 6 - 24 milligrams per deciliter)
-creatinine of 2.72 (measurement of how well your kidneys are filtering waste; normal is 0.7 - 1.3 milligrams per deciliter for men)
-B-type natriuretic peptide (BNP) of 5,845 (measurement of a protein made when your heart has to work harder to pump; higher levels of b-type natriuretic peptide can be a sign of heart failure; normal is less than 100 picograms per milliliter)
-initial high sensitive troponin was 85 (the first of a series of blood draws that detect a protein in the blood released when the heart muscle has been damaged; normal is below 14 nanograms per liter)
-one-hour high sensitivity troponin was 84 (a blood test drawn one hour after the first blood draw that detects a protein in the blood released when the heart muscle has been damaged; normal is belove 14 nanograms per liter)
-three-hour high sensitivity troponin was 80 (a blood test drawn three hours after the first blood draw that detects a protein in the blood released when the heart muscle has been damaged; normal is belove 14 nanograms per liter).
At 03:05 PM, Staff (U) placed an order for Lasix (diuretic) 40 milligrams to be administered. At 03:07 PM, Staff (O), Registered Nurse documented Patient #1 will transfer to a receiving hospital via private car with their spouse. At 03:12 PM, Patient #1's blood pressure was 192/87. At 03:16 PM, Staff (U), Physician Assistant ordered the saline trap can remain in place during transfer. At 03:19 PM, Lasix 40 mg was administered per Staff (U) Physician Assistant order. At 03:39 PM, Patient #1 was discharged via personal car to another hospital. At 04:50 PM, Staff (U) Physician Assistant documented they called the transfer center, Patient #1 will go to another hospital (higher level of care) for cardiac consult, echocardiogram, and admission, "Patient #1 is amenable to this and was transferred." Review of the "Acute Patient Transfer" form for Patient #1, dated 11/25/23, was incomplete and did not address Patient #1's medical condition, transfer arrangements, or risks of transfer specific to Patient #1's medical condition. The section for Consent to Transfer was not signed by Patient #1 or Patient #1's representative. The document was signed by Staff (U), Physician Assistant, however, there was no documentation found which indicated that Staff (U) consulted with the physician or that the physician agreed with the transfer.

Interview on 12/14/23 at 01:30 PM with Staff (U), Physician Assistant revealed a patient leaving by car would get instruction on where to go. Sometimes the physician assistant will sign the transfer form without the physician co-signature. Staff (U) will document if the patient is stable to transfer by car. The patient must consent to driving themselves by car for transfer. Staff (U) would not exclude a patient from being transferred by car that had high blood pressure, a deep vein thrombosis (blood clot), and was given Lasix within 30 minutes of discharge. It depends on the total condition of the patient. Staff (U) revealed they consult with the attending physician on a case-by-case basis. If the physician is consulted, the physician will cosign the physician assistant note. Sometimes the physician assistant will sign the transfer form without the physician co-signature. Staff (U) would document if they spoke to the physician about a transfer, and if the physician saw the patient. If the attending physician did not see the patient, Staff (U) would not document it.

2. Review of the Strong Memorial Hospital West Brockport emergency department medical record for Patient #7 revealed on 11/19/23 at 04:07 PM, Patient #7 presented to the emergency department for severe abdominal pain with nausea. A workup including bloodwork and a CT scan were ordered and obtained. At 04:07 PM, the resident indicated Patient #7's presentation is concerning for hepatitis with continued unrelieved pain. At 10:48 PM, nursing documented that Patient #7 departed via private car to another medical facility. Review of the "Acute Patient Transfer" form, dated 11/19/23, did not address risks of transfer specific to Patient #7's medical condition and was "checked off" to indicate Patient #7 consented to the transfer, however, the patient/responsible person signature sections were blank. (No evidence was found in the medical record to indicate Patient #7/patient representative consented to transfer to another medical facility and/or to be transferred via personal car.)

3. Review of the Strong Memorial Hospital West Brockport emergency department medical record for Patient # 8 revealed on 09/28/23 at 07:39 PM, Patient #8 presented to the emergency department for ear pain with drainage. Physician orders were placed for a CT scan to evaluate for signs of mastoiditis (a bacterial infection and inflammation of the mastoid bone, located behind the ear), antibiotics, and pain medication. On 09/29/23 at 08:20 AM, nursing documented that Patient #8 was transferred to another medical facility via ambulance. Review of the "Acute Patient Transfer" form, dated 09/28/23, did not provide detailed explanation of the risks of transfer specific to Patient #8's medical condition and the section indicating Patient #8 consents to or refuses transfer was not checked off and the patient/patient representative signature sections were blank. (No evidence was found in the medical record to indicate Patient #8/patient representative was informed of the risks of transfer based on medical condition and consented to transfer to another medical facility via ambulance.)

4. Review of the Strong Memorial Hospital West Brockport emergency department medical record for Patient #10, dated 09/08/23, revealed at 10:10AM, Patient #10 arrived ambulatory at the emergency department and was seen by Staff (LLL), Physician Assistant for the complaint of right-side neck pain and worsening bilateral extremity (hands/arm or feet/legs) numbness/tingling for three weeks with the right leg was "giving out." The CT scan (scan that uses x-ray and computer processing to create cross sectional images) showed severe degenerative (medical condition that causes a part of the body to become weaker or have less function) changes with canal stenosis (narrowing of the spine). The case was discussed with another hospital's transfer center, neurosurgery staff, and the emergency department team who accepted Patient #10 for transfer for a spine consult and possible MRI (use magnetic fields and radio waves to generate images) imaging. Patient #10 will transfer by personal vehicle. The spouse was aware to drive Patient #10 directly to the other hospital emergency department without stopping. At 02:20 PM, Patient #10 was discharged via personal car to another hospital. Review of the "Acute Patient Transfer" form for Patient #10, dated 09/08/23, did not address Patient #10's medical condition, transfer arrangements, or risks of transfer specific to Patient #10's medical condition. The document was signed by Staff (LLL), Physician Assistant, however, there was no documentation found which indicated that Staff (LLL) consulted with the physician or that the physician agreed with the transfer.

5. Review of the Strong Memorial Hospital West Brockport emergency department medical record for Patient #19, dated 10/01/23 revealed at 12:57 PM, Patient #19 arrived with their spouse and daughter and was seen by Staff (MMM), Physician Assistant for concerns for safety at home due to a progressive cognitive decline with a concern for dementia. A plan was made by Staff (MMM), to facilitate transfer to another hospital for physical and occupational therapies and evaluation for a higher level of care due to a decline at home. Review of the "Acute Patient Transfer" form for Patient #19, dated 10/01/23, revealed the section for risks of transfer were filled out as "no significant risk" and was not specific to Patient #10's medical condition. The document was signed by Staff (MMM), Physician Assistant, however, there was no documentation found which indicated that Staff (MMM) consulted with the physician or that the physician agreed with the transfer.

Interview on 12/15/23 at 09:25AM and 02:30 PM with Staff (M), Assistant Quality Officer verified emergency department staff failed to document that Patients #1 and Patient #10 were stable to transfer by personal vehicle to a higher level of care at another hospital. Instead, personal vehicles were used for the transfers. Staff (M) also verified emergency department staff did not obtain Patients #7 and #8 consent to transfer to another hospital.

Interview on 12/15/23 at 08:30 PM with Staff (L), Associate Quality Officer, verified that the physician assistant did not consult with the physician prior to a patient transfer, and the physician did not countersign the "Acute Patient Transfer" form to indicate agreement with the transfer order for Patients #1, #10, and #19. Staff (L) verified that Strong Memorial Hospital West Brockport does not have a policy that requires the Physician Assistant to consult with a physician prior to a patient transfer, and/or requires a physician to countersign the "Acute Patient Transfer" form to indicate agreement with the physician assistant transfer order.