HospitalInspections.org

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Based on observation, interview, record review, and review of hospital policies and procedures and medical staff bylaws, the hospital failed to develop and implement policies and procedures for evaluation and treatment of patients presenting for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to ensure patients receive a comprehensive medical screening examination by a qualified medical professional and stabilizing treatment prior to transfer or discharge risks poor health care outcomes, injury, and death.

Findings included:

1. The hospital failed to post signs in the hospital's obstetrical unit notifying patients they had a right to a medical screening examination (MSE) and necessary stabilizing treatment regardless of ability to pay for services; and whether or not the hospital participated in the Medicaid program (Cross Reference: Tag C2402).

2. The hospital failed to a) ensure that the hospital's medical staff bylaws identified the qualifications of physicians, mid-level providers, and registered nurses who performed medical screening examinations (MSE) in the hospital's emergency department and obstetrical unit; and b) ensure MSE's were performed by qualified health care providers (Cross Reference: Tag C2406).

3. The hospital failed to provide stabilizing treatment for Patient #1 within the capabilities of the staff and facilities available at the hospital (Cross Reference: Tag C2407).

4. The hospital failed to provide evidence that a) patients were informed of the risks and benefits of transfer if stabilization was not possible; b) the hospital ensured there was an accepting physician and hospital prior to transferring the patient; c) the hospital ensured patients were appropriately monitored during transport; and d) the hospital sent copies of all medical records pertaining to the patient's emergency care to the receiving facility when patients were transferred to another hospital (Cross Reference: Tag C209).
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Based on observation, interview, and review of hospital policies and procedures, the hospital failed to post signs in the hospital's obstetrical unit (OB) notifying patients they had a right to a medical screening examination (MSE) and necessary stabilizing treatment regardless of ability to pay for services; and whether or not the hospital participated in the Medicaid program

Failure to post this information risked violation of the patient's right to receive a medical screening examination, stabilizing treatment, and/or transfer regardless of ability to pay.

Findings included:

1. Review of the hospital's policy and procedure titled "Emergency Medical Treatment and Active Labor Act (EMTALA) Anti-Dumping Policy," Policy #1458 dated 05/24/19, showed that: each hospital department that provided emergency services would post signs in English and Spanish in places likely to be noticed by all individuals entering the department. The signs would include the statement that patients had the right to receive an appropriate MSE and necessary stabilizing treatment (including treatment of an unborn child). The signs would also include the statement that the hospital participated in the Medicare and Medicaid programs.

The policy did not state signs would be posted in areas where individuals would be waiting for examination and treatment.

2. On 10/22/19 at 9:20 AM during a tour of the hospital's OB unit, the investigator observed there were no signs posted at the unit entrance, in waiting areas, and in examination rooms notifying patients of their rights under EMTALA; and that the hospital participated in the Washington State Medicare and Medicaid program.

3. During an interview at the time of the observation, the FBC charge nurse (Staff #1) confirmed that there was no such signage.
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Based on interview, record review, and review of hospital policies and procedures and medical staff bylaws, the hospital failed to 1) ensure that the hospital's medical staff bylaws identified the qualifications of physicians, mid-level providers, and registered nurses who performed medical screening examinations (MSE) in the hospital's emergency department and obstetrical unit; and 2) ensure that a qualified health care provider performed a MSE for Patient #1.

Failure to ensure patients receive a comprehensive medical screening examination by a qualified medical professional and stabilizing treatment prior to transfer or discharge risks poor health care outcomes, injury, and death.

Reference: 42 CFR 482.55(b)(2) - "The hospital must staff the emergency department with the appropriate numbers and types of professionals and other staff who possess the skills, education, certifications, specialized training and experience in emergency care to meet the written emergency procedures and needs anticipated by the facility."

Findings included:

1. Review of the hospital's medical staff bylaws showed they did not identify the qualifications of physicians, mid-level providers, and registered nurses who performed MSE's in the hospital's emergency department and obstetrical (OB) unit.

2. Review of the hospital's policy and procedure titled "Emergency Medical Treatment and Active Labor Act (EMTALA) Anti-Dumping Policy," Policy #1458 dated 05/24/19, showed that a MSE would be performed by a "Qualified Provider." The policy defined a "Qualified Provider" as a doctor of medicine or osteopathy; a certified nurse midwife with medical staff privileges that included OB care; and a registered nurse with two or more years' experience as a labor and delivery nurse and basic life support and neonatal resuscitation program certification. These qualifications were not included in the medical staff bylaws.

3. On 10/22/19 at 8:45 AM, the emergency department (ED) charge nurse stated physician assistants routinely provided emergency care to patients. The policy above did not identify a physician assistant as a "Qualified Provider."

4. Review of the hospital's policy and procedure titled "Care of OB Triage Patients," Policy #6246 dated 05/15/19, showed that "Qualified Medical Personnel" would perform a MSE of obstetric patients at 20 weeks or greater gestation. The policy defined "Qualified Medical Personnel" as meeting the following requirements: Validation of labor and delivery unit competencies, as evidenced by completion of the orientation checklist and annual competency assessment; satisfactory completion of initial and annual job performance evaluation; successful completion of the Association of Women's Health, Obstetric and Neonatal Nurses intermediate fetal monitoring course; successful completion of unit-based education on EMTALA; and validation of MSE competency by the hospital educator and/or OB/GYN medical staff chair. These qualifications differed from the qualifications identified in Policy #1458 and were not included in the medical staff bylaws.

5. Review of the medical records for Patient #1 showed that a registered nurse (Staff #3) performed a MSE of Patient #1 in the hospital's obstetric unit on 09/16/19. There was no evidence in the record of another nurse or physician participating in the MSE.

6. On 10/23/19 at 3:10 PM during an interview with the investigator, the nursing director for the hospital's obstetric unit (Staff #5) stated that Staff #3 was currently in orientation.

7. Review of Staff #3's orientation checklist and personnel file on 10/23/19 showed she had been hired on 07/22/19. The nurse did not meet the requirements for "Qualified Provider" as defined in Policy #1458 nor "Qualified Medical Personnel" as defined in Policy #6246.
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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to provide stabilizing treatment for Patient #1 within the capabilities of the staff and facilities available at the hospital prior to transferring the patient to another hospital.

Failure to ensure patients receive stabilizing treatment prior to transfer or discharge risks poor health care outcomes, injury, and death.

Findings included:

1. Review of Astria Sunnyside Hospital's (ASH) policy and procedure titled "Emergency Medical Treatment and Active Labor Act (EMTALA) Anti-Dumping Policy," Policy #1458 dated 05/24/19, showed that patients had the right to receive an appropriate medical screening examination, necessary stabilizing treatment (including treatment of an unborn child), and an appropriate transfer to another facility regardless of the patient's ability to pay for services.

2. Review of the medical records for Patient #1 showed the following:

a. Patient #1 was a 19 year-old patient who came to ASH on 09/16/19 at 11:30 AM for a betamethasone injection (a steroid to promote maturation of the lungs of a fetus prior to delivery). A staff nurse in the hospital's obstetrical unit (Staff #3) assessed the patient at 12:16 PM and found the patient's blood pressure was 167/105 (normal range 90/60 mm Hg to 130/80). The nurse gave the injection at 12:20 PM and contacted the patient's physician (Staff #4) by telephone at 12:26 PM to report the patient's elevated blood pressure. The physician ordered a preeclampsia panel (blood tests for patients who experience high blood pressure during pregnancy) and a urine test.

b. The urine test results showed 2331.0 mg/dl protein (normal 0.0-12.0) and 20.83 protein/creatinine (normal 0.00-0.20). The nurse re-checked the patient's blood pressure and found the readings were 168/99 at 12:30 PM, 157/95 at 12:46 PM, 165/99 at 12:51 PM, 167/99 at 12:57 PM, 156/93 at 1:01 PM, 163/101 at 1:16 PM, and 163/101 at 1:24 PM. Elevated blood pressure and protein in the urine are signs of preeclampsia, a pregnancy complication characterized by high blood pressure, signs of damage to another organ system (most often the liver and kidneys), and risk for seizures.

c. Nursing notes written by Staff #3 showed that patient's physician was in the patient's room in the OB unit on 09/16/19 at 1:37 PM. The notes at 1:59 PM stated that the physician "discharged patient to a higher level of care facility related to elevated blood pressure"; that the patient would travel via private vehicle with a support person; and that the patient's medical records would be faxed to the hospital from the physician's office. The patient was discharged from the OB unit at 1:40 PM.

d. The patient's medical record did not include notes or assessment results written by the patient's physician. There was no evidence that the physician considered stabilizing treatment of the patient, such as administering medications to lower blood pressure and prevent seizures, before discharging the patient and sending the patient via a privately owned vehicle to Kadlec Regional Medical Center (KRMC) in Richland, Washington, which is 42 miles from ASH.

3. Interviews with hospital staff showed the following:

a. On 10/22/19 at 2:00 PM during an interview with the investigator, the registered nurse (Staff #3) confirmed the patient's physician had told Patient #1 to go from ASH to KRMC. She stated the physician told the patient, "Do not stop. Go now."

b. On 10/23/19 at 12:00 PM during an interview with the investigator, the patient's physician (Staff #4) confirmed he had discharged the patient and sent Patient #1 to KRMC for treatment.
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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to provide evidence that a) patients were informed of the risks and benefits of transfer if stabilization was not possible; b) the hospital ensured there was an accepting physician and hospital prior to transferring the patient; c) the hospital ensured patients were appropriately monitored during transport; and d) the hospital sent copies of all medical records pertaining to the patient's emergency care to the receiving facility when patients were transferred to another hospital, as demonstrated by 2 of 7 patients reviewed (Patient #1, #2).

Failure to inform the patient of the risks and benefits of transfer if stabilization is not possible risks violation of the patients' right to informed consent for treatment. Failure to ensure there is an accepting physician and hospital prior to transferring the patient risks sending the patient to a hospital that does not have the capacity or capability to care for the patient. Failure to ensure the patient and unborn child are appropriately monitored during transport risks injury and adverse outcomes related to the stressors of travel. Failure to send copies of the patient's medical records to the receiving hospital risks adverse patient outcomes due to lack of care continuity.

Findings included:

1. Review of hospital policies and procedures showed the following:

a. Review of Astria Sunnyside Hospital's (ASH) policy and procedure titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Anti-Dumping Policy," Policy #1458 dated 05/24/19, showed that patients had the right to receive an appropriate medical screening examination, necessary stabilizing treatment (including treatment of an unborn child), and an appropriate transfer to another facility regardless of the patient's ability to pay for services.

b. Review of the hospital's policy and procedure titled, "Interfacility and Intrafacility Transfer of Patients," Policy #220 dated 10/08/19 showed when patients were transferred to another hospital the attending physician would communicate with the accepting physician at the facility that would be receiving the patient. The ASH house supervisor would communicate with the house supervisor at the accepting facility to secure bed placement after receiving confirmation of an accepting physician. The house supervisor would make arrangements for transport of the patient by ground or air. The primary nurse caring for the patient would call the receiving hospital and report to the nurse who would be accepting the patient and give an estimated time of arrival. The physician would write a transfer order and complete an interfacility transfer form. Copies of the patient's medical records would be placed in an envelope and sent with the patient.

2. Review of the medical records for Patient #1 showed the following:

a. Patient #1 was a 19 year-old patient who came to ASH on 09/16/19 at 11:30 AM for a betamethasone injection (a steroid to promote maturation of the lungs of a fetus prior to delivery). A staff nurse in the hospital's obstetrical unit (Staff #3) assessed the patient at 12:16 PM and found the patient's blood pressure was 167/105 (normal range 90/60 mm Hg to 130/80). The nurse gave the injection at 12:20 PM and contacted the patient's physician (Staff #4) by telephone at 12:26 PM to report the patient's elevated blood pressure. The physician ordered a preeclampsia panel (blood tests for patients who experience high blood pressure during pregnancy) and a urine test.

b. The urine test results showed 2331.0 mg/dl protein (normal 0.0-12.0) and 20.83 protein/creatinine (normal 0.00-0.20). The nurse re-checked the patient's blood pressure and found the readings were 168/99 at 12:30 PM, 157/95 at 12:46 PM, 165/99 at 12:51 PM, 167/99 at 12:57 PM, 156/93 at 1:01 PM, 163/101 at 1:16 PM, and 163/101 at 1:24 PM. Elevated blood pressure and protein in the urine are signs of preeclampsia, a pregnancy complication characterized by high blood pressure, signs of damage to another organ system (most often the liver and kidneys), and risk for seizures.

c. Nursing notes written by Staff #3 showed that physician was in the patient's room in the OB unit on 09/16/19 at 1:37 PM. The notes at 1:59 PM stated that the physician "discharged patient to a higher level of care facility related to elevated blood pressure"; that the patient would travel via private vehicle with a support person; and that the patient's medical records would be faxed to the hospital from the physician's office. The patient was discharged from the OB unit at 1:40 PM.

d. The patient's medical record did not include evidence that the patient was informed of the risks and benefits of transfer if stabilization of her medical condition was not possible at ASH; that hospital staff or the patient's physician ensured there was an accepting physician and hospital prior to transferring the patient; that the patient and unborn child were appropriately monitored during transport; and that copies of all medical records pertaining to the patient's emergency care at ASH were sent to the receiving facility when the patient was transferred to another hospital.

3. Review of the medical records for Patient #2 showed the following:

a. Patient #2 was a 14 year-old patient who came to ASH on 04/22/19 with vaginal bleeding. The patient was at 32 weeks 4 days gestation. The patient received a MSE, was stabilized, and was transferred to another hospital on that date. The patient's medical record lacked evidence that copies of her medical records were sent to the receiving hospital.

b. Patient #2 returned to ASH on 05/04/19 at 34 weeks 2 days gestation with premature rupture of membranes (rupture of the amniotic sack before labor begins). The patient received a MSE and was transferred to another hospital on that date. The patient's medical record lacked evidence that the patient had been informed of the risks and benefits of transfer, that there was an accepting physician at the receiving hospital, that the receiving hospital had accepted the transfer, and that copies of her medical records were sent to the receiving hospital.

4. Interviews with hospital staff showed the following:

a. On 10/22/19 at 2:15 PM during an interview with the investigator, the OB nursing director (Staff #5) and OB charge nurse (Staff #1) confirmed that Patient #1 had not been transferred in accordance with EMTALA requirements and hospital policy.

b. On 10/22/19 at 3:40 PM during an interview with the investigator, the OB nursing director (Staff #5) and OB charge nurse (Staff #1) confirmed that the records for Patient #2 did not have evidence that the patient had been transferred in accordance with EMTALA requirements and hospital policy.

c. On 10/23/19 at 1:30 PM during a telephone interview with the investigator, the OB medical staff department chair (Staff #6) stated there was no process for providing EMTALA training for OB and family practice health care providers.

d. On 10/23/19 at 1:50 PM during an interview with the investigator, the Chief of Medical Staff (Staff #7) stated there was no process for providing EMTALA training for medical providers who did not work in the emergency department.
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