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Based on review of the facility's website, facility documents, medical records (MR), and interview with facility staff (EMP), it was determined the facility failed to ensure there was a complete on-call list of physicians available for general surgery posted in the emergency department, resulting in the transfer of four patients to other facilities for surgical consultation / intervention (MR6, MR7, MR36, and MR43).

Findings include:

Review on May 22, 2012, of the facility website revealed the following information: "Whether you live in Lackawanna or Luzerne Counties - or one of our many surrounding counties - we are just a short drive away. Approved by The Joint Commission, we are licensed for over 265 hospital beds, serve a network of more than 600 physicians in more than 40 specialties of medicine and employ over 1,000 men and women. ... An acute care facility, Regional Hospital of Scranton specializes in tertiary, cardiovascular, oncology and orthopaedic care." Under the section "About Us" a listing of services revealed "Surgical Services (inpatient, outpatient, infusion)."

Review of the facility's "Medical Staff Bylaws," dated last reviewed August 2011, revealed "... Article VI Emergency Medical Screening, Treatment, Transfer and On-Call Roster Policy ... 6.2 D The rotation call list, containing the names and phone numbers of the on call physicians shall be posted in the emergency room department."

Review on May 23, 2012, of the facility's policy "Emtala On-call" revealed "Procedure: 1. The hospital is responsible for adopting and enforcing an on-call policy that ensures compliance with the requirements of EMTALA and to maintain a list physicians who are on-call after the initial examination to provide treatment necessary to stabilize an individual with an "emergency medical condition." The medical staff bylaws or appropriate policy and procedure define the responsibility of on-call physicians to respond, examine and treat with emergency medical conditions and actions to be taken when a practitioner fails to respond."

Review of the facility's on-call listing revealed the following days had no coverage for surgical services: August 15-30, October 8-31, and December 16-31, 2011.

1) Review of MR6 revealed the patient presented to the emergency department at 10:35 on December 6, 2011, with complaints of abdominal pain. The diagnosis of acute appendicitis was confirmed by CAT scan. The documentation on the transfer sheet by the physician in the area titled reason for transfer revealed "no surgical coverage at the sending facility." The patient was transferred at 15:20.

2) Review of MR7 revealed the patient presented to the emergency department at 02:08 with complaints of abdominal pain. The diagnosis was appendicitis. The patient was transferred to another facility at 10:00 AM on December 31, 2011, for a surgical consult.

Interview with EMP1 on May 21, 2012, at 11:05 confirmed MR7 was transferred with a diagnosis of acute appendicitis. EMP1 confirmed there was no one on call for surgery on December 31, 2011.

3) Review of MR36 revealed the patient presented to the emergency department at 08:20 on October 16, 2011, with complaints of abdominal pain. Physician documentation revealed an impression of acute diverticulitis, perforated diverticulum. There was documentation in the nursing notes that two surgeons were called and were unable to come to the hospital for a surgical consult. The patient was transferred at 1300. The transfer sheet documentation was "definitive surgical case."

Review of the Operating Room (OR) schedule for October 16, 2011, revealed the OR was open on that date.

Interview with OTH2 on May 21, 2012 at 9:20 AM confirmed MR36 should not have been transferred. OTH2 confirmed MR36 should have been added to the OR schedule on October 16, 2011.

4) Review of MR43 revealed the patient presented to the emergency room with pain on the left side at 11:50 on October 14, 2011. The CAT scan (axial tomography) revealed a large splenic contusion with hemoperitoneum (blood in peritoneal cavity). The patient was transferred at 17:05. The transfer sheet documentation by the physician revealed the benefits of transfer as "surgical coverage, trauma center."

Interview with OTH1 on May 21, 2012, at 11:05 AM confirmed there were problems covering general surgery call for the last six months. OTH1 confirmed there were no documented guidelines provided to the emergency room physicians as to what they were to do on these days. OTH1 did state there were days OTH1 had arranged for another surgeon to be available. OTH1 was unable to provide documentation for this arranged coverage for the on-call schedule. OTH1 confirmed MR6, MR7, MR36 and MR43 were transferred because there was no surgical coverage.

Interview with OTH2 on May 21, 2012 at 9:20 AM confirmed that as a result of a loss of surgeons, the facility was having difficulties covering the general surgery call for the emergency room. OTH2 confirmed the problem occurred a "few times" in the past few months.

Interview with EMP8 at 11:25 AM on May 21, 2012, confirmed there were issues with general surgery coverage in the Emergency Department (ED). EMP8 confirmed some ED physicians would make calls to attempt to get surgical coverage and others would just transfer the patient.

Interview with OTH3 at 3:15 on May 22, 2012 confirmed there were issues with surgical on-call coverage.

Based on review of facility documents, medical records, (MR) and staff interview (EMP), it was determined the facility failed to maintain a central log on each individual who came into the Emergency Department, seeking assistance, refused treatment or whether he or she was transferred, admitted, stabilized and transferred or discharged for over two hundred (200) Emergency Department patients.

Findings include:

Review on May 21, 2012, of the facility policy "Emergency Care Unit EMTALA Central Log," approved February 16, 2011, revealed "Policy: Purpose: To require that each hospital tracks the care provided to each individual who comes to: the hospital seeking care for a medical condition or an emergency medical condition; the hospital's dedicated emergency department seeking care for a medical condition; or Policy: Each hospital that provides emergency services must maintain a central log to include information on each individual who comes to the dedicated emergency department seeking examination or treatment for a medical condition or comes to the hospital property requesting evaluation or treatment for what may be an emergency medical condition. The central log includes by reference patient logs from departments of the hospital including the dedicated emergency departments, or other on or off campus departments and on campus provider-based departments where a patient might present seeking examination or treatment for a medical condition. Ancillary logs are incorporated into the Central Log by reference and maintained in such a manner that the same central core of information is maintained in all logs. The central log and any ancillary logs will be available within a reasonable amount of time for surveyor review. The central log and all ancillary logs must contain at a minimum: the date and time of arrival, the name of the individual, the name of the primary care provider and the following dispositions and time of disposition: Left before evaluation (eloped). Evaluated but refused treatment (left ama). Evaluated non-emergent and discharged. Evaluated,treated, stabilized and discharged. Evaluated, treated, stabilized and transferred. Evaluated, treated, not stabilized and transferred. Evaluated, treated and admitted to inpatient unit. Expired or dead on arrival. The central log must be retained for EMTALA purposes for a minimum of five years from the date of the screening. All Logs will be reviewed quarterly for identification and follow up of non-compliance issues.

Review of Emergency Department Logs on May 21, 2012, for October, November and December 2011 and January, February, March, and April 2012 revealed over two hundred instances of incomplete information for the time of seeking assistance, refusal of treatment, transfers, admissions, stabilized and transferred, or discharges.

Interview with EMP3 on May 21, 2012, at approximately 10:00 AM, confirmed the Emergency Department log was incomplete and did not contain the criteria defined for an Emergency Department Log.

Interview with EMP3 on May 21, 2012, at approximately 10:15 AM confirmed the guidelines for a complete Emergency Department Log were not met as required by the facility's policy.

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the facility failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed for two of 50 medical records reviewed (MR12 and MR30).

Findings include:

Review of the facility's "Rules and Regulations," dated August 2011, revealed "... Article VI Emergency Medical Screening, Treatment, Transfer and On Call Roster Policy 6.1(a) Screening (1) any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition. Generally, an 'emergency medical condition' is defined as active labor or as a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment to bodily organs or function, or serious jeopardy to the health of the individual or unborn child. (2) Examination and treatment of emergency medical conditions shall not be delayed in order to inquire about the individual's method of payment or insurance status, nor denied on account of the patient's inability to pay..."

Review of facility policy and procedure "Medical Screening Examination," dated approved November 4, 2011, revealed "Any individual who comes to the Emergency Department, Hospital Property or Premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by individuals qualified to perform such examination to determine whether or not an emergency condition exists. ... Providing the Medical Screening Examination ... 1. Regional Hospital of Scranton is obliged to perform the Medical Screening Examination to determine if an emergency medical condition exists. 2. In providing a Medical Screening Examination, the Regional Hospital of Scranton shall not discriminate against any individual because of diagnosis (e.g. labor, AIDS), financial status (e.g. uninsured, Medicaid) race, color, national origin, or handicap. 3. There shall be no delay in providing a Medical Screening Examination or follow-up treatment for an emergency medical condition in order about the patient's method of payment, insurance status, collection of co-payments or deductibles due or to sign financial responsibility forms or advance beneficiary notices. 4. Patients who inquire about financial responsibility for emergency care will be encouraged to delay such discussion until after completion of the Medical Screening Examination. There patiens will also be told that the hospital will provide a Medical Screening Examination and stabilizing treatment, regardless of their ability to pay. 5. Individuals coming to the emergency department must be provided a Medical Screening Examination beyond initial triage. Triage is not equivalent to a Medical Screening Examination. Triage merely determines the "order" in which patient swill be seen, not the presence or absence of an emergency medical condition. 6. Depending on the patient's presenting symptoms, the Medical Screening Examination may range from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies an procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT (Computerized Axial Tomography) scans an other diagnostic tests and procedures. 7. A Medical Screening Examination is not an isolated event. It is an on-going process. The record will reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this evaluation documented in the medical record prior to discharge or transfer."

Review of MR12 revealed the patient had presented to the ED with the complaint of chest tightness on February 22, 2012, at 18:06 PM. The patient was triaged at 21:50 PM. Review of nursing documentation revealed the nursing assessment was initiated at 22:08 PM. There was no evidence of medical screening examination by the physician. The patient eloped from the ED without being seen by the physician.

Review of MR30 revealed the patient had presented to the Emergency Department (ED) with complaint of chest tightness and burning on April 13, 2012, at 06:46 AM. There was no evidence of a medical screening examination by the physician. The patient left the ED at 07:12 AM without being seen by the physician.

Interview with EMP 5 confirmed the medical screening examinations for MR30 and MR12 were not performed by the physician.

Cross Reference
489.24(d)(4-5) Delay in examination and treatment

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure there was no delay in treatment for patients who presented with chest pain on the 11:00 PM to 07:00 AM shift for two of 50 medical records reviewed (MR12 and MR30).

Findings include:

Review of the facility's "Rules and Regulations," dated August 2011, revealed "... Article VI Emergency Medical Screening, Treatment, Transfer and On Call Roster Policy 6.1(a) Screening (1) any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition. Generally, an 'emergency medical condition' is defined as active labor or as a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment to bodily organs or function, or serious jeopardy to the health of the individual or unborn child. (2) Examination and treatment of emergency medical conditions shall not be delayed in order to inquire about the individual's method of payment or insurance status, nor denied on account of the patient's inability to pay..."

Review of facility policy and procedure "Medical Screening Examination," dated approved November 4, 2011, revealed "Any individual who comes to the Emergency Department, Hospital Property or Premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by individuals qualified to perform such examination to determine whether or not an emergency condition exists. ... Providing the Medical Screening Examination ... 1. Regional Hospital of Scranton is obliged to perform the Medical Screening Examination to determine if an emergency medical condition exists. 2. In providing a Medical Screening Examination, the Regional Hospital of Scranton shall not discriminate against any individual because of diagnosis (e.g. labor, AIDS), financial status (e.g. uninsured, Medicaid) race, color, national origin, or handicap. 3. There shall be no delay in providing a Medical Screening Examination or follow-up treatment for an emergency medical condition in order about the patient's method of payment, insurance status, collection of co-payments or deductibles due or to sign financial responsibility forms or advance beneficiary notices. 4. Patients who inquire about financial responsibility for emergency care will be encouraged to delay such discussion until after completion of the Medical Screening Examination. There patiens will also be told that the hospital will provide a Medical Screening Examination and stabilizing treatment, regardless of their ability to pay. 5. Individuals coming to the emergency department must be provided a Medical Screening Examination beyond initial triage. Triage is not equivalent to a Medical Screening Examination. Triage merely determines the "order" in which patient swill be seen, not the presence or absence of an emergency medical condition. 6. Depending on the patient's presenting symptoms, the Medical Screening Examination may range from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies an procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT (Computerized Axial Tomography) scans an other diagnostic tests and procedures. 7. A Medical Screening Examination is not an isolated event. It is an on-going process. The record will reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this evaluation documented in the medical record prior to discharge or transfer."

Review of facility document "Regional Hospital of Scranton Consent for Treatment," revealed "1. Assignment of Insurance Benefits/Promise to Pay: I hereby assign payment and authorize payment directly to the Facility, and to any facility-based physician, all insurance benefits, sick benefits, injury benefits, due because of ... I understand that I am responsible for any charges not covered by insurance company. ... 3. EMTALA (Emergency Treatment and Labor Act): The Facility is obliged to treat medical emergencies regardless of my ability to pay. Therefore, if I or my guarantor have a medical emergency or if I am a pregnant woman in labor, I have the right to receive, within the capabilities of this Hospital ' s staff and facilities, an appropriate medical screening examination, necessary stabilizing treatment, and if medically necessary, an appropriate medical transfer to another hospital, even if I cannot pay or do not have medical insurance or am not eligible to receive Medicare or Medicaid."

Review of MR12 revealed the patient presented to the ED with the complaint of chest tightness on February 22, 2012, at 18:06 PM. The patient was triaged at 21:50 PM. Review of the nursing documentation revealed the nursing assessment was initiated at 22:08 PM. There was no documentation of a medical screening examination by the physician. The patient eloped from the ED without being seen by the physician.

Review of MR30 revealed the patient presented to the Emergency Department (ED) on April 13, 2012, at 06:46 AM complaining of chest tightness and burning. Continued review of MR 30 revealed a blank ED order sheet. The order sheet documented "LBS (Left Without Being Seen) =@ [sic] 7:12". Continued review of MR30 revealed the "Regional Hospital of Scranton Consent for Treatment" was signed by the patient at 06:48 AM. Further review of the Consent for Treatment revealed the patient's medical insurance information was completed and printed at the bottom of the form. Review of the "Regional Hospital Hospital of Scranton ER Registration" for MR30 revealed all pertinent patient identifying information, including insurance information, was completed.

Interview with EMP2 on May 21, 2012, at approximately 2:00 PM confirmed their understanding of the EMTALA regulation. EMP2 confirmed the registration data was to be obtained following triage by the nurse. EMP2 confirmed the registration face sheet was generated following triage. EMP2 confirmed there was no documentation of a triage assessment for MR30. EMP2 confirmed a patient presenting with chest pain or tightness was to be taken directly to triage for evaluation. EMP2 confirmed when MR30 presented to the ED at 06:46 AM, the patient who had presented before MR30 was taken back for assessment, and MR30 remained in the waiting area. EMP2 confirmed the next patient presented to the ED for treatment was 10:27 AM.

Telephone interview with EMP13 on May 22, 2012, at approximately 9:00 AM confirmed MR30 presented to the ED at 06:46 AM with chest tightness and the patient was registered at 06:48 AM. EMP13 told the patient to return to the waiting room and a nurse would be right out to take the patient to the triage area. EMP13 called back to the ED and notified the nurse that a patient with chest pain was present in the waiting room. EMP13 revealed that at 7:00 AM, EMP13 went to the another part of the registration area to assume other job duties and found out MR30 was upset and left the hospital.

Continued interview with EMP13 revealed the registration of ED patients on night shift was obtained before the patient was triaged because of insufficient staff for that shift. EMP13 confirmed the process was different on the day shift because there was an assigned triage nurse. EMP13 confirmed there was no assigned triage nurse on the off shifts.

Interview with EMP8 on May 22, 2012, at 11:25 confirmed patients presenting to the ED with complaints of chest pain were to be taken into the ED immediately with only a quick registration (name and date of birth) for forms. EMP8 confirmed the process on 11-7 was to register first and then take the patient into the ED for examination, as there was one clerk and no triage nurse.

Interview with EMP12 on May 22, at 11:25 revealed a patient with chest pain was to be taken right back for evaluation. EMP12 confirmed a patient with chest pain was never to be sent back to the waiting room. EMP12 confirmed there was no triage nurse on the 11-7 shift.

Interview with EMP7 on May 22, 2012, at approximately 11:40 confirmed registration forms and consent forms were not to be completed and signed until after the patient was triaged. EMP7 confirmed a patient with chest pain was to be taken right back for evaluation.

Interview with EMP11 on May 22, 2012, at 11:50 AM confirmed only a quick registration was to be completed prior to triage. Quick registration was basic information for forms. EMP11 further confirmed the face sheet could appear on the chart prior to triage if the patient was at the facility in the past. EMP11 confirmed if the consent for treatment was signed by the patient a full registration had taken place, which would include insurance information.

Cross Reference
489.24(4) and 489.24(c) Medical Screening Exam

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure all patients transferred were provided with an explanation of the risks and benefits of the transfer and informed consent, failed to ensure the sending physician spoke with the receiving physician to confirm acceptance of the patient, and failed to ensure medical records were provided to the receiving facility for three of three psychiatric records where the patient was transferred to another facility (MR11, MR14 and MR48).

Findings include:

Review of the facility's "Medical Staff Rules and Regulations," dated approved August 2011, revealed "... Article VI Emergency Medical Screening, Treatment, Transfer and On-Call Roster Policy ... 6.1C Transfer ... 3. Upon transfer, the Emergency Department shall provide a copy of appropriate medical records regarding its treatment of the individual including, but not limited to, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of any test, informed written consent or transfer certification, and the name and address of any on-call physician who has refused or failed to appear within a reasonable period of time in order to provide stabilizing treatment."

Review on May 22, 2012, of the facility's policy "Patient Transfer Policy," last reviewed February 25, 2012 revealed "When the physician determines that a medically urgent condition exists, treatment is provided to stabilize the patient's condition to assure within reasonable medical probability that no deterioration of condition is likely to occur on transfer. If stabilization cannot be accomplished, transfer may be pursued when: Attending physician certifies in writing the medical necessity for transfer and obtains informed consent for same, having communicated risks, benefits and care alternatives: or Patient or responsible individual requests transfer having been informed by the physician regarding associated risks, benefits and care alternatives."

Review of MR11 revealed the patient presented to the emergency room on May 16, 2012, as a result of drug ingestion and depression. The patient was transferred via ambulance to another facility. There was no documentation of a signed certification for transfer form which included an explanation of the risks, benefits and care alternatives, informed consent by the patient or evidence that results of all tests were sent to the receiving facility. There was no documentation the sending physician spoke with the receiving physician to confirm acceptance of the patient.

Review of MR14 revealed the patient presented to the emergency room on February 26, 2012, with suicidal ideation. The patient was transferred via ambulance to another facility. There was no documentation of a signed certification for transfer form which included an explanation of the risks, benefits and care alternatives, informed consent by the patient or evidence that results of all tests were sent to the receiving facility. There was no documentation the sending physician spoke with the receiving physician to confirm acceptance of the patient.

Review of MR48 revealed the patient presented to the emergency room on September 24, 2011, with suicidal ideation and depression. The patient was transferred via ambulance to another facility. There was no documentation of a signed certification for transfer form which included an explanation of the risks, benefits and care alternatives, informed consent by the patient or evidence that results of all tests were sent to the receiving facility. There was no documentation the sending physician spoke with the receiving physician to confirm acceptance of the patient.

Interview with EMP5 on May 22, 2012 confirmed that the medical records did not have the required documentation for transfer and the facility did no follow its processes.