HospitalInspections.org

Based on interviews with hospital staff, observation of 2 of 2 EMTALA transfer drills, the review of 2 of 2 EMTALA transfer drill critiques, and the review of policies and procedures, it was determined that the hospital failed to ensure the implementation of its Emergency Medical Treatment and Active Labor Act (EMTALA) policies and procedures related to the acceptance of transfers from referring hospitals.

Findings include:

The review of the hospital's policy titled "EMERGENCY TREATMENT AND ACTIVE LABOR ACT (EMTALA)" dated as last approved on 07/29/2011 reflected "2. EMTALA regulations provide that a hospital that has the capability to treat a patient with an emergency medical condition must accept the transfer of an individual needing those capabilities from a referring hospital without those capabilities, if the sending hospital is anywhere within the boundaries of the United States. 3. Transfers are made physician-to-physician." The policy included the following requirements "Transferring a patient who is present in another facility's emergency department who has been stabilized within the limits of that facility's current capabilities to PMMC. A. Any hospital department employee receiving a request to transfer a EMTALA patient to PMMC transfers the call to the Nursing Supervisor. B. PMMC's Nursing Supervisor validates whether the situation involves an EMTALA-related patient by asking the requesting facility if the patient is currently in their emergency department...2, [.] If yes, the Nursing Supervisor collects appropriate information from appropriate personnel in the requesting facility's emergency department. 3. Nursing Supervisor determines PMMC's capacity...D. If PMMC has capacity, the Nursing Supervisor contacts the appropriate on call physician. E. If transfer is accepted by the on call physician, the Nursing Supervisor confirms transfer with the requesting facility. Details of the transfer are documented in the Nursing Supervisor's daily report."

The review of the hospital's policy titled "DIVERT PROCEDURE" dated as last approved 07/13/2011 reflected "2. EMERGENCY DEPARTMENT (ED)/EMS DIVERT...b. If PMMC is green for trauma the trauma surgeon will be notified by the ED Charge Nurse. The ED Charge Nurse will also contact the Nursing Supervisor at RVMC (Rogue Valley Medical Center)." The hospital's policy and procedure did not include that any hospital department employee receiving a request to transfer an EMTALA patient to PMMC transfers the call to the Nursing Supervisor as designated in the hospital's EMTALA policy and procedure.

An observation of an EMTALA transfer drill was conducted on 08/17/11 at 0815. During the drill, a call was placed to the dedicated telephone number for transfer requests by the Risk Manager/Safety Officer. The staffing coordinator answered the phone and was informed that a drill was being conducted whereby a nearby ED (emergency department) was requesting the transfer of a trauma patient with facial injuries. He/she said "I am not the nursing supervisor" and "Let me take your name and phone number and I'll contact the manager of the nursing department and [he/she] will call you back." The manager of the nursing supervisors called back in approximately one minute and was informed of the same drill information. He/she confirmed that the hospital had capacity; he/she said he/she would provide the caller with the on-call trauma surgeon's phone number in order to facilitate physician to physician contact. He/she did not indicate that he/she would contact the appropriate on call physician, and if the transfer was accepted by the on call physician, confirm the transfer with the requesting facility in accordance with the hospital's policy and procedure. This information was reviewed and verified with the Risk Manager/Safety Officer on 08/17/11 at 1005.

A second observation of an EMTALA transfer drill was conducted on 08/17/11 at approximately 0845. During the drill, a call was placed to the hospital's ED phone by the Risk Manager/Safety Officer. The ED charge nurse was informed of the same drill information. He/she said he/she would provide the caller with the trauma surgeon and OMF [oromaxillofacial] physicians' phone numbers in order to facilitate physician to physician contact. He/she said he/she would contact the supervisor by calling the supervisor's pager number. He/she further said that he/she was aware that supervisor's handle in-coming calls, but during a "gap" period from 0730 to 1100, there is no nursing supervisor assigned. He/she said during that time period the ED charge nurse handles the transfer calls that come into the ED by providing the transferring ED with the trauma physician's phone number and accepting the patient. He/she said he/she was unaware of the dedicated telephone number for EMTALA transfers. He/she further said that when the nursing supervisor is assigned, he/she would contact the nursing supervisor by calling the supervisor's pager number. He/she provided the pager number, and he/she verified that it was not the same number as the dedicated telephone number for EMTALA transfers. He/she was unaware of how to notify the nursing supervisor of a transfer request during a 3.5 hour nursing supervisor schedule "gap," and therefore did not demonstrate the ability to follow the hospital's policy and procedure that directed "Any hospital department employee receiving a request to transfer a EMTALA patient to PMMC transfers the call to the Nursing Supervisor." He/she further did not demonstrate understanding of the dedicated telephone number for EMTALA transfer requests as indicated in the hospital's EMTALA violation plan of correction, that was to be implemented by 08/05/2011. This information was reviewed and verified with the Risk Manager/Safety Officer on 08/17/11 at 1005.

A critique of the drills was completed and received by the Risk Manager/Safety Officer on 08/17/2011 at 1130. Review of the documentation contained in the critique reflected "2. Is there a policy/procedure in place on how to respond to this event? Yes___ No___," and "Yes" was indicated. The documentation further reflected "If yes, was the policy and procedure followed? Yes___No___," and "No" was indicated. Further review reflected "Manager of Nursing Supervisors did not follow policy...regarding contacting the on-call physician and then contacting the requesting facility [.] ED Charge Nurse did not transfer the call to the Nursing Supervisor [.] Comments: There is a gap of time from 0730-1100h M-F where there is no Nursing Supervisor on duty; however Manager of Nursing Supervisors provides coverage during this time...Scenario B: Call to...Charge Nurse...ED Charge Nurse provided readily accessible contact numbers for on-call trauma surgeon and on-call oral surgeon for physician to physician communications [.] When Nursing Supervisor is available, the ED Charge Nurse would also provide Nursing Supervisor pager number to the facility (stated that there is no coverage from 0730-1100h) [.] ED Charge Nurse stated she handles transfers in to ED during gap but would also alert Nursing Supervisor when and if available...4. What could be improved?..ED Charge Nurse not aware of coverage for Nursing Supervisor between (0730-1100h) for transfers in to ED (Coverage is provided by Manager of Nursing Supervisors) [.] ED Charge Nurse not aware of Nursing Supervisors cell phone number but is aware of the variety of other ways to contact Nursing Supervisor."