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Based on interview, record review and policy review, the facility failed to comply with the conditions of participation outlined in §489.24; (refer to Appendix V). The facility failed to document the physician explained the risks and benefits of refusing ambulance transfer to a higher level of care and failed to obtain signatures indicating the patient understood the risks and benefits for 4; failed to send medical records to the receiving facility for 2; failed to provide an appropriate MSE for 2; and failed to provide an appropriate transfer for 3 of 20 sampled patients who required stabilizing treatments. Findings include:

1. Review of the facility's policy titled, "EMTALA: Screening, Stabilization, Transport," dated 4/11/22, showed when an individual comes to the hospital and a request is made for examination or treatment of a potential emergency medical condition, the individual will receive an appropriate medical screening examination to determine whether the individual has an emergency medical condition.

-Review of patient #s 2 and 5 EHRs failed to show the facility provided appropriate medical screening examinations in order to determine if the patient had an emergency medical condition, and what was the extent of the medical condition. (see C-2406)

2. Review of the facility's policy titled, "EMTALA: Screening, Stabilization, Transport," dated 4/11/22, showed following the completion of the medical screening examination, if the patient has an emergency medical condition, the QMP will provide stabilizing treatment or transfer if a higher level of care is needed. The policy showed if the patient refused treatment or transfer, the provider was to, "... a. give the individual an explanation of the risks and benefits ... of the examination or treatment or mode of transportation. b. describe in ... medical record the examination and treatment or that [sic] the individual refused. c. take reasonable steps to obtain the written informed refusal ... The document reflecting the refusal should indicate that the individual has been informed of the risks and benefits ... and should be signed ... and placed in the medical record." The policy showed when a patient is transferred the facility is responsible for sending copies of all available medical records related to the emergency medical condition to the receiving facility.

-Review of patient #s 1, 2, 4, and 11 EHRs failed to show the risks and benefits of the patient's refusal for transfer were explained to the patient or their representative, and failed to show written consent or refusal of the transfers. Review of patient #1's EHR failed to show the required medical records were sent to the receiving facility. (see C-2408)

3. Review of the facility's policy titled, "Trauma Transfer Guidelines," dated 8/2/23, showed a transfer is considered appropriate if, "a. Injuries are outside the scope of care offered by [Facility Name] ..., b. Level of nursing care needed cannot be met at [Facility Name]," and "c. At attending providers discretion" [sic] The policy also showed all appropriate transfer paperwork must be filled out prior to transfer with copies sent with the patient and the rationale for transfer must be clearly documented in a provider note, "including risks and benefits of mode of transport."

-Review of patient #s 14, 15, and 17 EHRs failed to show properly completed transfer certification explaining the risks and benefits of transfer to the patient or their representative and failed to show written consent or refusal of the transfer. Review of patient #14's EHR failed to show the consulting physician co-signed the transfer certification for a patient transferred in an unstable condition, patient #15's EHR failed to show the required medical records were sent to the receiving facility, and patient #17's EHR failed to show the provider signature was appropriately dated and time. (see C-2409)

Based on interview and record review, the facility failed to maintain an accurate central log which included all patients who came to the ED seeking emergency care, whether the patient refused treatment, was refused treatment, or was transferred, admitted and treated, stabilized and transferred, or discharged. Findings include:

During the entrance conference on 5/20/24 at 10:45 a.m., a request was made for the ED log and the full ED census from 11/1/23 to 5/19/24.

Review of the ED census report showed the following:
- ED encounters for November of 2023, 81 total;
- ED encounters for December of 2023, 75 total;
- ED encounters for January of 2024, 88 total;
- ED encounters for February of 2024, 69 total;
- ED encounters for March of 2024, 88 total;
- ED encounters for April of 2024, 73 total; and
- ED encounters from 5/1/24 to 5/19/24, 61 total.

Review of the facility's central log, dated 11/1/23 to 5/19/24, showed the following:
- ED encounters for November and December of 2023, no encounters in the log;
- ED encounters for January of 2024, 72 written in the log, 16 encounters missing from the log;
- ED encounters for February of 2024, 58 written in the log, 11 encounters missing from the log;
- ED encounters for March of 2024, 84 written in the log, four encounters missing from the log;
- ED encounters for April of 2024, 64 written in the log, nine encounters missing from the log; and
- ED encounters from 5/1/24 to 5/19/24, 57 written in the log, four encounters missing from the log.

During an interview on 5/21/24 at 8:15 a.m., staff member B stated the previous DON (who was no longer at the facility) identified the ED log was not being maintained prior to 1/1/24. Staff member B stated the ED log was restarted on 1/1/24.

During an interview on 5/23/24 at 8:00 a.m., staff member G stated the ED log was not being completed prior to 1/1/24. Staff member G stated she did not know the purpose of the ED log and was directed to enter all ED patients into the log.

During an interview on 5/23/24 at 9:00 a.m., staff member H stated she had been at the facility for more than 20 years. Staff member H stated the ED log was not done for several years and she was not sure why "it went away or why it came back." Staff member H stated she was not aware the ED log was an EMTALA requirement.

During an interview on 5/23/24 at 11:00 a.m., staff member K stated she was at the facility from July of 2023 through January of 2024. Staff member K stated the use of an ED log initially was not used and near the end of her assignment, they started using a log.

During an interview on 5/23/24 at 11:30 a.m., staff member L stated she had been at the facility since February of 2024. Staff member L stated she believed the ED log was used for documenting the arrival and discharge disposition for ED patients. Staff member L stated she did not remember getting education regarding the use or consequences of not completing the ED log.

Based on interview and record review, the facility failed to ensure the patient received an adequate medical screening examination (MSE) and failed to obtain a signed Against Medical Advice (AMA) form which identified the risks and benefits of the patient's refusal to be admitted or transferred for further care for 2 (#s 2 and 5) of 20 sampled patients. Findings include:

1. Review of patient #2's EHR, dated 5/15/24, showed the patient, a 26-year-old female, presented to the ED via ambulance after fainting at home. The patient lost consciousness for approximately 10 seconds and fell to the floor. The patient's vital signs on arrival to the ED were BP 99/67, P 89, R 17, T 37.0 and an O2 saturation of 94% on room air. The patient's BP remained low throughout the ED encounter, going as low as 84/50. The patient had a history (approximately one year ago) of extensive blood clots in her lungs. The patient had a surgical procedure to remove the blood clots and was placed on a blood thinning medication to prevent the development of new clots. The provider's physical examination failed to show examination of the patient's spinal bones for fracture, dislocation, or pain after sustaining a fall. The examination also failed to show the provider assessed the resident's brain, cranial nerve function, or arm and leg strength for evidence of a brain injury or stroke. Laboratory tests, an EKG, and CTs of the head and chest were performed. The results of the CT of the patient's chest showed multiple lesions, some with cavities (bubble-like formations). The provider's assessment and plan at discharge failed to show the lung lesions or any recommended follow-up. The provider documented the patient declined admission or transfer for further care and would be leaving AMA. The patient's EHR failed to show the patient signed anything showing she was notified of the risks and benefits of her refusal or that she was leaving AMA.

During an interview on 5/23/24 at 8:00 a.m., staff member G stated she was instructed by staff member F to document the patient and their representative were thoroughly counseled regarding the risks and benefits of refusing treatment and leaving AMA. Staff member G stated she documented the information in the patients medical record, but she did not complete the AMA form.

During an interview on 5/28/24 at 9:00 p.m., staff member F, a mid-level provider in the ED, stated he did not consider patient #2 as an AMA discharge. Staff member F stated the patient was feeling better and already had a follow-up appointment scheduled with a specialist. Staff member F stated, "a comprehensive work-up ruled out a stroke, no blood clots, was probably dehydrated and orthostatic." Staff member F stated the patient was concerned about cost because she did not have health insurance, and already had a follow-up appointment scheduled within a week. Staff member F stated he only discharges patients AMA in extreme cases. He stated he usually does a regular discharge and gives the patient instructions to return if any problems. Staff member F stated he always discusses the risks and benefits with the patient and representative. However, when time is a factor he sometimes forgets to include it in the ED note.

2. Review of patient #5's EHR, dated 4/3/24, showed the patient presented to the ED after sustaining a right hand injury while using a table saw. Patient #5 was observed to have a deep laceration to the base of his right index finger. The patient's vital signs on admission to the ED were BP 161/92, P 111, R18, O2 saturation 96% on room air and T 36.6. Plain x-ray films of the patient's right hand showed no boney abmormailities, only soft tissue disruption at the base of the patient's right index finger. Because the patient was not able to straighten his index finger, a tendon injury was suspected. Staff member D, the ED physician, examined patient #5's injury which showed the laceratiom was to the joint at the base of the patient's index finger, but failed to identify if there was any visible damage into the joint itself. The ED note did show the provider was aware of the patient's history of lung cancer and current treatment with chemotherapy. Staff member D consulted an orthopedic specialist regarding the care of this patient's injury. The note failed to show whether or not staff member D informed the orthopedic specialist regarding the patient's current treatment with chemotherapy. Staff member D's note showed he was instructed to clean the wound, loosely close the laceration with stitches, immobilize the index finger and cover the wound with a bandage. The note also showed the patient was instructed to follow-up with an orthopedic hand specialist in the next couple of days. The patient's EHR failed to show any testing or evaluation of the patient's immune system, which can be depressed during chemotherapy. A depressed immune system placed the patient at a higher risk for infections in the soft tissue or in the bone itself.

During an interview on 5/22/24 at 3:30 p.m., staff member D stated there were no associated risks if the follow-up on the hand injury was delayed up to seven days. Staff member D did not mention patient #5's potential for a depressed immune system related to chemotherapy as a risk for patient #5.

Review of patient #5's operative note, dated 4/4/24, showed the patient had a surgical repair of his injured right hand on 4/4/24. The note showed the surgeon was able to see damage to the cartilage at the end of the hand bone which formed the base of the patient's index finger. The cartilage around a joint is called the capsule. The damage to the capsule created an opening into the joint itself. Exposing the joint to air increased the risk of infection into the joint itself. The operative report showed the wound was cleaned out, the capsule was repaired, the tendons were repaired, and the wound was closed.

Based on record review, interview, and policy review the facility failed to document the ED physician explained the risks and benefits of the patient's refusal to be transported by ambulance to a higher level of care and failed to obtain signatures indicating the patient understood the risks and benefits of the refusal for 4 (#s 1, 2, 4, and 11); and failed to send medical records to the receiving facility for 1 (#1) of 20 sampled patients. This deficiency had the potential to affect the patients' decision to be transferred via ambulance and affect the care they received at the receiving facility. Findings include:

1. Review of patient #1's EHR, dated 5/16/24, showed the patient, a 17-year-old male, had sustained a significant hand injury due to an accident with a power tool. The record showed the patient arrived at the facility at 9:56 a.m., via ambulance. The provider notes showed the patient had x-rays before and after an attempt to reduce the fractures. The provider documented he attempted to close the wound but was unable. The provider, after consulting an orthopedic surgeon, made the decision to transfer the patient to another facility for possible surgical intervention, as the fingers were unlikely to be saved and the sending facility did not have surgical capabilities. The note showed the provider recommended transferring via ambulance for pain control. The patient's guardian refused to allow the patient to go by ambulance and took patient #1 by private vehicle after the patient was discharged. The patient's EHR failed to show a written provider certification of the risks and benefits of transfer and a patient or representative consent or refusal for the ambulance transfer. The EHR failed to show a tranfer form was filled out identifying if records were sent to the receiving facility.

During an interview on 5/23/24 at 12:00 p.m., staff member M stated he did not usually do transfer forms when a patient went by private vehicle. Staff member M stated this was because the patient was no longer under the control of the facility, and they were discharged.

Review of the facility's form entitled, "[Facility Name] Transfer Form, not dated, showed a check box for, "Copies of appropriate medical records sent with patient."

2. Review of patient #2's EHR, dated 5/15/24, showed the patient presented to the ED via ambulance after having a syncopal episode and a loss of consciousness at home. The patient's vital signs on admission were BP 99/67, P 89, R 17, T 37.0, and O2 sat 94% on room air. Laboratory tests, an EKG, and CTs of the head and chest were performed. The provider note showed he recommended the patient be transferred for additional testing not available at the facility. The provider documented the patient refused transfer and would leave AMA. The EHR failed to show documentation of the provider's risk versus benefit discussion with the patient, or a refusal of transfer or AMA form signed by the patient.

During an interview on 5/28/24 at 9:00 a.m. staff member F, a mid-level provider, stated patient #2's refused to be transferred to a higher level of care. Staff member F stated he wanted the patient to go but decided she was stable enough to wait for the already scheduled appointment later in the week. Staff member F stated the patient was feeling much better and the high-risk diagnoses of stroke and pulmonary embolism had been ruled out as the reason for not having the patient sign an AMA form.

3. Review of patient #4's EHR, dated 5/15/24, showed the patient presented to the ED with swelling and redness to his right index finger and had a history of a cut about one month prior. The patient's vital signs were within normal limits and laboratory tests were normal. Patient #4's x-ray was "concerning for a septic joint." Arrangements were made for patient #4 to be seen immediately by an orthopedic specialist at Hospital B. The patient refused ambulance transfer and was discharged, with plans to travel to Hospital B by private vehicle. The EHR failed to show the risks and benefits of the transfer were discussed with the patient and a signed consent or refusal by the patient.

During an interview on 5/23/24 at 11:30 a.m., staff member L, an ED RN, stated she did not complete transfer paperwork for patients transferring to a higher level of care who went by private vehicle. Staff member L stated patient #4 was sent to a higher level of care but transported by private vehicle.

4. Review of patient #11's EHR, dated 1/22/24, showed the patient presented to the ED with a right ankle injury sustained in a fall. X-rays showed a displaced fracture of the right lower leg and a displaced fracture of the inner ankle bone. Staff member D attempted to reduce the patient's fractures twice. Staff member D consulted an orthopedic specialist at Hospital B. The orthopedist reviewed the x-rays and recommended the patient come to the ED to see if he could get better alignment of the fractures. The patient was instructed to go directly to Hospital B. The patient was marked as discharged by staff member D, although staff member G documented the patient was transferred to another facility. The record failed to show a signed provider certification of the risks versus benefits of a transfer by private vehicle, or a signed consent by the patient.

During an interview on 5/23/24 at 8:00 a.m., staff member G, an ED RN, stated she usually completed the transfer paperwork (signed provider and patient consent for transfer and the transfer form). Staff member G stated if a patient wanted to travel by private vehicle, she still did the transfer paperwork. Staff member G was not able to explain why the transfer paperwork was not completed for patient #11.

During an interview on 5/23/24 at 11:00 a.m., staff member K stated the paperwork process for discharge versus transfer was a "bit of a gray area." Staff member K was a travel nurse and was not aware of the facility's protocol for transferring versus discharge. Staff member K stated she completed the same discharge paperwork regardless of whether the patient went by private vehicle or by ambulance to another facility. Staff member K stated if the patient refused to go by ambulance, she tried to get an AMA form signed.

Review of the facility's policy titled, "EMTALA: Screening, Stabilization, Transport," dated 4/11/22, showed following the completion of the medical screening examination, if the patient has an emergency medical condition, the QMP will provide stabilizing treatment or transfer if a higher level of care is needed. The policy showed if the patient refused treatment or transfer, the provider was to, "... a. give the individual an explanation of the risks and benefits ... of the examination or treatment or mode of transportation. b. describe in ... medical record the examination and treatment or that [sic] the individual refused. c. take reasonable steps to obtain the written informed refusal ... The document reflecting the refusal should indicate that the individual has been informed of the risks and benefits ... and should be signed ... and placed in the medical record." The policy showed when a patient is transferred the facility is responsible for sending copies of all available medical records related to the emergency medical condition to the receiving facility.

Based on interview, record review and policy review, the facility failed to provide a properly completed certificate of transfer for 3 (#s 14, 15, and 17); and failed to provide patient records to the receiving hospital for a facility transfer for 1 (#15) of 20 sampled patients who required stabilizing treatment. This failure could cause unintended adverse medical consequences for the transferred patient. Findings include:

1. Review of patient #14's EHR dated 1/1/24, showed the patient presented to the ED via ambulance after having been involved in a motor vehicle accident. The patient sustained a number of life-threatening injuries. Arrangements were made for the patient to be transferred by air to the closest trauma center. The patient's transfer form indicated the patient's condition had not been stabilized prior to the transfer and failed to show the co-signature of the consulting physician.

During an interview on 5/22/24 at 2:15 p.m., staff member E, a mid-level provider, stated she was not aware a physician needed to sign the transfer consent when a patient was unstable at the time of transfer. Staff member E stated she did the transfer paperwork for patient #14. Staff member E stated when an unstable patient in the ED needed to be transferred, she would complete the transfer paperwork as quickly as possible and discussed the patient's condition with the receiving facility physician. Staff member E stated she was not aware when the patient in the ED was unstable at the time of transfer, a physician (from the sending facility) must be consulted and co-sign the transfer certificate.

Review of patient #14's Emergency Department Reports, dated 1/1/24, showed staff member E consulted the ED physician at the receiving facility and obtained an acceptance of pateint #14 for transfer to the receiving facility. The report does not show any consultation with a physician at the sending facility.

Review of patient #14's transfer form, dated 1/1/24, showed staff member E documented the patient's condition had not been stabilized. The form also contained a boilerplate statement, "Based on the reasonable risks and benefits to the patient ... the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility out weight [sic] the increased risks ..." The specific risks and benefits portion of the form was blank. The mid-level provider (staff member E) signed the form. There was no physician co-signature on the form.

Review of the facility's policy titled, "EMTALA: Screening, Stabilization, Transport," dated 4/11/22, showed when a patient has an EMC that has not been stabilized, the patient may be transferred to another facility if the transfer is appropriate, the QMP has consulted with a physician to determine if the benefits outweigh the risks of transfer, and the QMP has signed a certification containing a summary of the specific risks and benefits of the transfer. The consulting physician must co-sign the certification "reasonabl soon." An appropriate transfer is defined as a transfer where the facility has provided the medical treatment within its capability, has obtained acceptance of the patient by the receiving facility, and has used qualified personnel and equipment to affect the transfer safely.

2. Review of patient #15's EHR, dated 1/2/24, showed the patient presented to the ED with complaints of leg pain since falling approximately one week prior. The patient's swelling and pain were worse in his left leg. Laboratory tests showed an elevated D-dimer level which can indicate blood clots. The ED provider determined the patient needed to have an ultrasound of his legs to rule out blood clots. The closest facility with ultrasound capabilities at night was Hospital C. The EHR showed the patient was instructed to go directly to Hospital C's ED. The transfer form failed to show what medical records were sent to the receiving facility.

3. Review of patient #17's EHR, dated 1/24/24, showed the patient presented to the ED with a fever and vomiting. The patient's vital signs showed an elevated pulse (109) and an elevated temperature (39.2 Celsius = 102.5 Fahrenheit). The ED provider determined the patient should have a viral respiratory panel and CSF fluid analysis, which were not available at the sending hospital. The ED provider made arrangements for the patient to be transferred to Hospital C. The patient was discharged to go directly to Hospital C ED by private vehicle. The EHR failed to show the date and time the form was signed by the provider.

Review of the facility's policy titled, "EMTALA: Screening, Stabilization, Transport," dated 4/11/22, showed transfer is defined as, "The movement (including discharge) of an individual outside the Hospital's facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the hospital ..."

Review of the facility's policy titled, "Trauma Transfer Guidelines," dated 8/2/23, showed transfer is considered appropriate if, "a. Injuries are outside the scope of care offered by [Facility Name] ..., b. Level of nursing care needed cannot be met at [Facility Name]," and "c. At attending providers discretion" [sic] The policy also showed all appropriate transfer paperwork must be filled out prior to transfer with copies sent with the patient and the rationale for transfer must be clearly documented in a provider note."