HospitalInspections.org

Based on hospital Medical Staff Bylaws, Rules and Regulations review, policy reviews, medical record reviews, physicians and staff interviews the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings include:

1. The hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 23 sampled DED patients (#18) who presented to the hospital for evaluation and treatment and was escorted out of the hospital's DED by Security personnel; and the DED Labor and Delivery (L&D) physician failed to certify in the medical record prior to discharge that a patient who presented to the hospital's DED L&D for contractions was in false labor and not true labor for 1 of 2 sampled DED L&D patients (#25); and the hospital leadership failed to ensure individual(s) determined qualified and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction to provide appropriate MSE was defined by the hospital's Medical Staff bylaws or rules and regulations for 1 of 1 hospital's Medical Staff bylaws, rules and regulations reviewed (Hospital A).

~ Cross refer to §489.24(r) and §489.24(c) Medical Screening Examination - Tag A2406.

2. The hospital's Dedicated Emergency Department (DED) and/or Labor and Delivery (L&D) physician failed to ensure an appropriate transfer; by failing to complete a written physician's certification for transfer documenting the medical benefits and increased risks associated with the transfer for the specific Emergency Medical Condition (EMC); and failed to ensure the written physician's certification was signed and/or dated and timed by the transferring physician to closely match the time of transfer for 4 of 4 sampled patients that were transferred with an EMC to other acute care hospitals (DED #13, #21, #3, and L&D #20).

~ Cross refer to §489.24(e)(1)(2) Risks and Benefits, Tag A2409.

Based upon hospital Medical Staff bylaws, rules and regulations review, policy reviews, medical record reviews, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 23 sampled DED patients (#18) who presented to the hospital for evaluation and treatment and was escorted out of the hospital's DED by Security personnel; and the DED Labor and Delivery (L&D) physician failed to certify in the medical record prior to discharge that a patient who presented to the hospital's DED L&D for contractions was in false labor and not true labor for 1 of 2 sampled DED L&D patients (#25); the hospital leadership failed to ensure individual(s) determined qualified and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction to provide appropriate medical screening examinations (MSE) was defined by the hospital's Medical Staff bylaws or rules and regulations for 1 of 1 hospital's Medical Staff bylaws, rules and regulations reviewed (Hospital A).

Findings included:

1. Review on 10/28/2015 of current facility policy "EMTALA (EMERGENCY MEDICAL TREATMENT AND LABOR ACT): MEDICAL SCREENING, STABILIZATION, AND TRANSFER", Policy: 509, revised 12/2012, revealed "...II. PURPOSE AND APPLICABLE LAW: ...It is the policy of (Hospital A) to provide an appropriate medical screening examination, regardless of ability to pay, to persons requesting care or treatment on the hospital campus to determine the nature and extent of their injury, medical condition and/or pregnancy and to provide such additional care within the capabilities of the hospital and staff to stabilize the condition of the patient or to provide for an appropriate transfer. ...III. DEFINITIONS ...C. Emergency Medical Condition - a condition that manifests itself by such acute and severe symptoms that in the absence of immediate medical attention could reasonably result in serious jeopardy of the health of the individual (or an unborn child), serious impairment to bodily functions, or serious dysfunctions of any bodily organ or part. ...Examples of medical emergencies include: severe pain... D. Appropriate Medical Screening Examination - a screening to determine, with reasonable clinical confidence, whether an emergency medical condition exists. The medical screening examination must be uniform for all patients who present with similar complaints. ...IV. PROCEDURE: A. Patient Evaluation and Treatment ...1. EMTALA is triggered when a person 'comes to the emergency department' and a request is made by that individual or on his or her behalf for an examination or treatment of 'a medical condition'... 2. The medical screening exam will be provided within the capability of the hospital's emergency department and will include ancillary services routinely available to the emergency department. ...7. If the patient refuses to consent to a medical screening examination or to further stabilization treatment: a. Provide the individual with an explanation of the risks and benefits to the individual of the examination and/or treatment. b. Describe in the medical record the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. c. Take all reasonable steps to obtain the individual's....written informed refusal of the examination and/or treatment. The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. The document should be signed, if possible, by the individual....dated and placed in the individual's medical record. ...E. Medical Screening Examination A medical screening examination is provided to every presenting patient to determine within reasonable clinical confidence whether an emergency medical condition exists. This medical screening is uniform for all patients who present with similar complaints and within the capabilities of this hospital including ancillary services available to the emergency department. ..."

Hospital A, closed DED record review on 10/27/2015 for Patient #18, revealed a 44 year old female presented ambulatory via private transportation to the hospital's DED on 09/17/2015 at 0931. Review of an "Emergency Services Triage Registration Form" revealed "Reason for Visit: Pelvic hurting, Rt (right) side hurting, lower back and leg pain (hand written by Patient #18)." Review revealed "If in pain please circle current level" with a circle around "5 Hurts Worst." Further review revealed "Vaginal Discharge Yellow" and "Odor" hand written on the left side of the form. Review of Triage documentation revealed the patient was triaged by RN #1 at 0933. Review revealed a "Stated Complaint: PELVIC PAIN, FLANK PAIN" and "Chief Complaint: Pelvic Pain." Review of Pivot Triage Assessment documentation at 0933 by RN #1 revealed, "Pain Level 5" (0 - no pain, 5 worst pain). Further review revealed "History of present illness PT (patient) reports pelvic pain for the past 2 weeks. Pt denies any urinary sx (symptoms). Pt reports yellow vaginal discharge with an odor. Pt able [sic] with a steady gait." Review revealed vital signs were assessed as Temperature (T) 98.5 degrees Fahrenheit (F), Heart Rate (HR) 92, Respirations (R) 20, Pulse Oximetry (P/Ox) 99% on room air (RA), Blood Pressure (BP) 130/81. Review revealed pain was assessed as 5, Quality was constant and achy. Review revealed the patient was triaged as a priority 3 (Emergency Severity Index 1-5, 1 most severe, 5 least severe). Review revealed the patient was placed into treatment room #9 at 0952. Review of Nursing assessment documentation at 1013 by RN #2 revealed, level of consciousness - awake, alert, and appropriate. Patient oriented to person, place, time, and events. Skin - dry, pink, intact, warm. Skin turgor - good. Respiratory - breath sounds clear, breathing is unlabored, respiration pattern normal, respiratory effort normal. Cardiovascular - normal peripheral pulses, regular rate, rhythm. Abdomen is soft, non-tender. Nausea/Vomiting - Yes. Bowel sounds normal active all quadrants. Review revealed "Pt presents to ED with c/o (complaints of) pelvic pain. Pt states she is having 5/5 constant aching pain in her pelvis and back radiating to legs. Pt has no tenderness with palpation. Pt c/o nausea denies vomiting, denies urinary symptoms. Review revealed at 1031, discharge documentation - condition at discharge "Unchanged." Patient discharged ambulatory. Verbalized understanding of discharge instructions "No." Review revealed "Pt dc'd (discharged) to ED lobby escorted by security after attempting to assault Dr. (Physician A) name. Pt ambulated with fast paced gait stating 'Don't f....k with me.' Pt did not receive discharge instructions." (38 minutes after placement in treatment room #9). Review revealed an MSE was initiated by Physician A at 1010. Review of MSE documentation by Physician A, revealed "Chief Complaint: Pelvic Pain" and "Stated Complaint: PELVIC PAIN, FLANK PAIN." Review revealed "Notes: ...female presents with complaints of pelvic back pain chronic. pt denies any new concerns. Pt denies any fevers or chills" Review revealed a Past Medical History of hypertension, asthma, ovarian cysts, arthritis, musculoskeletal trauma. Review revealed a Past Psychiatric Medical History of anxiety, bipolar disorder, depression, and schizophrenia. Review of ROS (Review of Systems) revealed "...GASTROINTESTINAL: admits to abdominal pain. GENITOURINARY: Denies difficulty urinating, painful urination, burning, frequency, blood in urine, or discharge. FEMALE GENITOURINARY: Denies vaginal bleeding, heavy or abnormal periods, irregular periods. Denies vaginal discharge or odor. ..." Review of Physical Examination revealed, "GENERAL: Obese, angry female ...LUNGS: breathing with no difficulty ABDOMEN: Soft, nontender, nondistended abdomen. No guarding, no rebound. No masses appreciated. Female GU: deferred ...PSYCH: Angry...". Review revealed at 1030 "44-year-old female who was seen here very often for random pains presents with complaints of pelvic pain. Patient states that we must throughout [sic] her pain is from and that she does not have a primary care physician for [sic] I did explain to the patient that we would gladly evaluate her but that she needed OB/GYN to followup with. Lab work has already been ordered, I think the patient [sic] she will be receiving, [sic] and not narcotics at this point the patient became aggressive violent and began yelling, stood up and went to punch pain [sic] the face. I explained to the patient that she needs to calm down and sit down she again this patient [sic] in my face at which point for my own safety I left the room and had security escort the patient off the premise. IGiven [sic] that patient is here often, I expect her to return if there are any continued issues." Review revealed "Clinical Impression: Pain in pelvis Condition: Stable Disposition: HOME, SELF-CARE Additional Instructions: You have been removed off the premises and [sic] for aggressive behavior. When you have stopped threatening staff and stopped threatening to kill the physician you may return for further evaluation."

Review revealed the following physician's orders were entered by Physician A for Patient #18 at 1012 and were canceled. (Patient discharged prior to collection.):
1. Tylenol 975 mg by mouth;
2. Complete Blood Count with Differential;
3. Comprehensive Metabolic Panel;
4. Hcg Qualitative, Urine (pregnancy test);
5. Lipase; and
6. Urinalysis.

Further record review failed to reveal any available documentation the patient was given written discharge instructions for aftercare follow-up. Record review failed to reveal any available documentation the patient refused care or left against medical advice (AMA).

Interview on 10/28/2015 at 1028 with Physician A revealed he had been on the medical staff for 14-15 months. Interview revealed he was employed by the hospital's contracted emergency physicians' group. Interview revealed he was the DED attending physician on-duty who performed the MSE on Patient #18 when she presented to the DED on 09/17/2015. Interview revealed "the patient had been in the ED 17-18 times in the past year." Interview revealed "she is a known narcotic abuser, always coming in with pain complaints." Interview revealed "I have known her from visits before." Interview revealed the patient came in with complaints of back and pelvic pain. Interview revealed she was in room 9 or 10. Interview revealed "I walked into the room. Introduced myself. She had chronic back/pelvic pain. I explained I can evaluate and treat her but she would have to follow-up with OB/GYN for pelvic pain." Interview revealed "I told her I would not be giving her narcotics and would be treating her with anti-inflammatories. She jumped out of bed and became violent. She took a swing at my face." Interview revealed "she was a big woman." Interview revealed "I stepped back. I was examining her at the time." Interview revealed "I was conducting a normal PE (physical exam), head to toe." Interview revealed "I did not get to listen to her lungs or heart, this is when the patient swung at me." Interview revealed the patient did not report any vaginal discharge or odors during the exam. Interview revealed "It (yellow vaginal discharge and odor) was documented on the original nurse's note." Interview revealed "she admitted only to abdominal, pelvic, and back pain." Interview revealed "I asked the patient to sit and calm down and she took a swing at me again." Interview revealed "I took her behavior to indicate I would not be doing a pelvic exam." Interview revealed the female genitourinary exam was deferred. Interview revealed "the plan was to do a pelvic exam." Interview revealed "if the patient had acted normal and cooperative a pelvic exam would have been performed." Interview revealed "the patient threatened me, said she was going to kill me." Interview revealed "I left the room, and called security after she tried to punch at me twice." Interview revealed "my physical exam and her vital signs is what I based my decision on, that she was stable and could be discharged." Interview revealed "she had an exam, nothing was acute from her vital signs, so I discharged her." Interview revealed "I told the patient she could return when she was no longer violent towards the staff and threatening to kill me." Interview revealed the patient did not receive any written discharge aftercare follow-up instructions. Interview revealed "she stormed off." Interview revealed the patient was "escorted out by security." Interview revealed labs and Tylenol (for pain) had been ordered. Interview revealed "I ordered the labs before I entered the room." Interview revealed "I am not sure if they were collected and performed." Interview revealed the patient had been evaluated and "the labs would not have changed the treatment for the patient." Interview revealed "the exam showed no tenderness, no neuro deficits, and she was able to move around." Interview revealed "the patient was stable and did not have a emergency medical condition." Interview revealed "I called security for safety." Interview revealed "I do not recall if I asked the patient to be escorted out or if the patient stormed out."

Note: Medical record reviews revealed transcription errors. Interview revealed the following clarification of the medical record by Physician A for his MSE entry dated 09/17/2015 at 1030 - "44-year-old female who is seen here very often for random pains presents with complaints of pelvic pain. Patient states that we must find out where her pain is coming from and that she does not have a primary care physician. I did explain to the patient that we would gladly evaluate her but that she needed OB/GYN to followup with. Lab work has already been ordered, I told the patient she would be receiving anti-inflammatories and not narcotics. At this point the patient became aggressive violent and began yelling stood up and went to punch me in the face. I explained to the patient that she needs to calm down and sit down. She again tried to punch me in the face at which point for my own safety I left the room and had security escort the patient off the premises. Given that the patient is here often, I expect her to return if there are any continued issues."

Interview on 10/28/2015 at 1005 with RN #2 revealed she was a DED nurse. Interview revealed she was the primary treatment nurse for Patient #18 on 09/17/2015. Interview revealed the patient was at Pivot triage, then placed into treatment room #9. Interview revealed the patient complained of pelvic and back pain down her legs. Interview revealed the patient denied urinary symptoms and had no tenderness to her abdomen and back. Interview revealed the patient's pain was reported as a 5 out of 5, a constant achy pain. Interview revealed "Dr. (Physician A) had gone into do an evaluation." Interview revealed "I was in a room next door, when I heard the patient yelling." Interview revealed "I came out of the room and saw security walking beside her (Patient #18), kind of behind her. She was walking quickly." Interview revealed "She screamed 'Don't F....k with me." Interview revealed she did not witness any interactions between the patient and Physician A. Interview revealed the patient was "pleasant and cooperative with me." Interview revealed "I do not know why her mood changed." Interview revealed "she was cursing, but I don't know why." Interview revealed she did not know who called security or the names of the security guards who escorted the patient out of the ED. Interview revealed "I do not know why she was escorted out." Interview revealed "I do not know if the patient made the decision to leave." Interview revealed the patient did not receive any written discharge or follow-up instructions. Interview revealed labs had been ordered but nothing collected prior to the patient leaving. Interview revealed "Dr. (Physician A) told me he went into the room and explained to the patient that she would be getting some lab work and Tylenol and the patient became upset and tried to punch him."

Telephone interview on 10/28/2015 at 1134 with RN #1 revealed she was a DED nurse. Interview revealed she was the Pivot triage nurse on 09/17/2015 when Patient #18 presented to the DED. Interview revealed she "vaguely" recalls the patient. Interview revealed the patient complained of pelvic pain, and yellow vaginal discharge with an odor. Interview revealed the patient reported her pain as a 5/5. Interview revealed she was triaged a priority 3. Interview revealed she recalled security escorting the patient out of the ED for causing a disturbance in back and posing a threat. Interview revealed she had no other interactions with the patient and did not witness any interactions between the patient and Physician A.

Interview on 10/28/2015 at 1103 with Security Officer (SO) #1 revealed he was a security officer on-duty 09/17/2015 during the day shift (0530-1400). Interview revealed he received a call that a patient (Patient #18) had been discharged from the ED and did not want to leave the treatment room. Interview revealed SO #2 assisted and was the first security officer on-scene. Interview revealed when he arrived to the ED, the patient was at the treatment room doorway "on her way out." Interview revealed the patient stated that we did not have to follow her. Interview revealed the two security officers escorted the patient out of the ED to the greeter doors. Interview revealed the patient was talking on her cell phone. Interview revealed the patient was cooperative and complied with the request to leave. Interview revealed "nothing was said about an incident involving the patient being violent and aggressive." Interview revealed "It was my understanding the staff wanted the patient out of the room and the patient just did not want to leave." Interview revealed "there was no mention the patient had been violent or aggressive towards the physician." Interview revealed "we were asked to escort her out of the ED." Interview revealed he did not witness any aggressive or violent behaviors or use of profanity by the patient. Interview revealed when security is called for patients with violent or aggressive behaviors, "we talk with them and try to calm them down." If staff can not deescalate the situation, restraints can be used, or call police for assistance. Interview revealed "normally we try to handle it in-house." Interview revealed the incident was not recorded in the security log book because it was considered routine.

Interview on 10/28/2015 at 1121 with SO #2 revealed he was a security officer on-duty 09/17/2015 during the day shift. Interview revealed he remembers the incident involving Patient #18. Interview revealed he was in the security office and received a phone call that security was needed in the ED. Interview revealed he went to the ED. Interview revealed "Dr. (Physician A) met me at the nurses' station and wanted the patient in room #8 or #9, escorted out of the building." Interview revealed "I was unsure of the events or why he wanted the patient escorted out." Interview revealed he was assisted by SO #1. Interview revealed the patient stated she did not need to be escorted out and was not worried about the hospital. Interview revealed the patient told us not to touch her. Interview revealed as the patient was walking out she called someone on her cell phone and was talking about the hospital. Interview revealed "the patient was angry and cussing as she was walking." Interview revealed the patient stated "you better not F....king touch me." Interview revealed the patient was cooperative. Interview revealed he did not witness any aggressive or violent behaviors from the patient. Interview revealed "Dr. (Physician A) was out of the room in the middle of the nurses' station when I arrived." Interview revealed "I was unaware the patient tried to assault Dr. (Physician A)." Interview revealed staff are trained on how to handle patients with violent and aggressive behaviors. Interview revealed staff are to try to deescalate the situation, can use restraints with a physician's order, or call the local police department for assistance. Interview revealed "we talk before we touch." Interview revealed the incident was not recorded in the security log because it was routine and did not involve any physical contact.

Interview on 10/29/2015 at 1432 with Physician G revealed he was the DED Medical Director for Hospital A. Interview revealed he reviewed the patient's DED record for her 09/17/2015 visit in response to a grievance filed by the patient with the hospital. Interview revealed "the standard of care for the complaint (pelvic pain and yellow vaginal discharge with odor) is to have a pelvic exam done." Interview revealed "the patient should have received a pelvic exam, but there was extenuating circumstances by both parties." Interview revealed "a different approach of deescalating would have served useful." Interview revealed "when taken into context the totality of frequent visits and that the patient was a danger to our staff, I don't think there was an EMC at the time."

2. Review on 10/28/2015 of current facility policy "EMTALA (EMERGENCY MEDICAL TREATMENT AND LABOR ACT): MEDICAL SCREENING, STABILIZATION, AND TRANSFER", Policy: 509, revised 12/2012, revealed "...II. PURPOSE AND APPLICABLE LAW: ...It is the policy of (Hospital A) to provide an appropriate medical screening examination, regardless of ability to pay, to persons requesting care or treatment on the hospital campus to determine the nature and extent of their injury, medical condition and/or pregnancy and to provide such additional care within the capabilities of the hospital and staff to stabilize the condition of the patient or to provide for an appropriate transfer. ...III. DEFINITIONS ...C. Emergency Medical Condition - a condition that manifests itself by such acute and severe symptoms that in the absence of immediate medical attention could reasonably result in serious jeopardy of the health of the individual (or an unborn child), serious impairment to bodily functions, or serious dysfunctions of any bodily organ or part. ...D. Appropriate Medical Screening Examination - a screening to determine, with reasonable clinical confidence, whether an emergency medical condition exists. ...G. Labor - means the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in true labor unless a physician, certified nurse midwife, or other qualified medical person (as defined in the medical staff bylaws) certifies that, after a reasonable time of observation, the woman is in false labor. ...E. Medical Screening Examination A medical screening examination is provided to every presenting patient to determine within reasonable clinical confidence whether an emergency medical condition exists. This medical screening is uniform for all patients who present with similar complaints and within the capabilities of this hospital including ancillary services available to the emergency department. ..."

Review on 10/28/2015 of current facility policy "LABOR CHECKS", Policy: 6190-31, revised 02/20/2013, revealed "Patients at 20 weeks gestation or greater presenting to (Hospital A) with obstetrical complaints will be seen on the Labor and Delivery Unit. ...3. If patient is not admitted: ...c. Document medical diagnosis as ordered by M.D./C.N.M. ..."

Hospital A, closed DED L&D record review on 10/28/2015 for Patient #25 revealed the patient presented to the L&D via wheelchair from home on 10/25/2015 at 1731 with a chief complaint of "Suspected Rupture of Membranes; Vaginal Bleeding." Review of triage nurse documentation at 1800 by RN #6 revealed, fetal movement - present, contractions - frequent, vaginal bleeding - normal show, vaginal discharge - present. Review revealed "Patient Complaints Contractions." Review revealed pain on admission was assessed as 3/5 (0 pain free, 5 worst pain), pain presence - intermittent, pain type - contractions, pain location - abdomen and back, pain related to contractions - yes. Review revealed membranes status - intact, speculum results - small amount bright red blood, mucous tinged. Review revealed dilatation 1-2 cm (centimeters), effacement (%) - 40-50 effaced, station - minus 3, consistency - soft, position - midposition, total Bishops Score 5 (5-8 = Small percentage of induction failure). Review revealed level of consciousness - fully conscious, DTR's (deep tendon reflex)/Clonus - DTRs 2 plus; No Clonus, extremity movement - full range of motion. Review revealed heart rhythm - regular, nailbeds - pink, capillary refill - less than 3 seconds. Review revealed respiratory effort - unlabored, regular rhythm, breath sounds (left and right) - clear and equal. review revealed skin color - normal for race, skin temperature - warm, moisture - dry. Review revealed Fetal evaluation - monitor mode - External US (ultrasound), FHR (fetal heart rate) baseline rate (bpm) - 145. Review revealed procedures - sterile vaginal exam. Review revealed at 1802, vaginal bleeding - normal show; vaginal Exam - dilatation 1.0 cm, effacement (%) - 50, station - minus 2, exam by - (RN #6). At 1830, contraction frequency 1.5-5 per minute, duration - 30-110 seconds, quality mild/moderate, FHR 145. At 1859, "Communication Provider orders received" and "Provider Notified....Dr. (Physician E)" and "Notification Reason Status Update; Fetal Status; Labor Status; Membrane Status; Uterine Activity; Pain; Bleeding; Lab/Diagnostic Study" and "Communication Comments Provider notified of negative fem results, sterile speculum exam, sterile cervical exam, reactive FHTs (fetal heart tracing), contraction pattern, maternal vital signs, vaginal bleeding, and urinalysis. Orders received to monitor vaginal bleeding for four hours with pad count and reassess after four hours." At 1900, contraction frequency 3-5, duration - 60-100 seconds, quality mild, FHR 140. Review revealed documentation by RN #4 at 1930, contraction frequency 3-5 per minute, duration 50-80 seconds, quality mild/moderate, FHR 145. At 2000, contraction frequency 2-5 per minute, duration 50-70 seconds, quality mild/moderate, FHR 150. At 2049, "Fetus A Comments Baby very active." At 2138, vaginal bleeding - small, vaginal exam - dilatation 1.0 cm, effacement (%) 0 (zero), station - minus 1, exam by (RN #4), Vaginal Exam Comments - "small amount of blood mixed with mucous noted on glove. Peri-pad is same pad has had one [sic]. Old blood noted with smears of fresher blood. No area of saturation noted. At 2145, "Dr. (Physician E) notified of u/c (uterine contractions) pattern, bleeding and repeat vag (vaginal) exam. Orders received." At 2201, "Pt d/c'd (discharged) to home via w/c (wheelchair) with care notes on early labor. Instructed to keep appointment tomorrow in office." Review of a "Discharge Record Chart" at 2211 by RN #4 revealed, discharged to home, accompanied by husband, via wheelchair. Review revealed "Discharge Condition Stable" and "Discharged By Dr. (Physician E)." Discharge pain 3/5. Review of a "Physicians Order Form" revealed a telephone order obtained by RN #4 from Physician E on 10/25/2015 at 2145 to "D/C home." Record review revealed no available documentation of an MSE conducted by Physician E. Record review revealed no available documentation of a medical diagnosis. Record review revealed no available documentation Physician E, a certified nurse-mid wife, or other qualified medical person acting within his or her scope of practice as defined in hospital medical staff bylaws and State law, certified that, after a reasonable time of observation, Patient #20 was in false labor upon being discharged from the hospital and not true labor.

Telephone interview on 10/29/2015 at 1145 with Physician E revealed she was a locum tenens (temporary substitute) physician. Interview revealed her specialty was OB/GYN. Interview revealed 10/24-25/2015 was her "first coverage" for L&D at Hospital A. Interview revealed she was on-call for coverage when Patient #20 presented to L&D for evaluation. Interview revealed she did not come into the hospital to evaluate the patient at bedside. Interview revealed she consulted and communicated with the L&D nurses via telephone. Interview revealed she was not required to come in to evaluate the patient unless requested by the nurse. Interview revealed based on the information provided by the L&D nurse the patient's diagnosis was "False Labor" or "Latent Labor." Interview revealed she
did not document any notes in the patient's medical record. Interview revealed she did not verbally give the nurse a medical diagnosis over the telephone to record in the medical record. Interview revealed "I assumed it would be reviewed in Medical Records (department) and a diagnosis would be given based on the nursing notes." Interview confirmed Physician E did not certify in the medial record that after a reasonable time of observation, Patient #20 was in false labor and not true labor.

Interview on 10/29/2015 at 1445 with RN #4 revealed she had worked on the Labor and Delivery Unit for 4 years. Interview revealed RN #4 explained the responsibility of the RN performing a labor check as: "anything pertaining to pregnancy" like, intake history, give medications, perform vaginal checks, use amnisure (test strip) to rule out ruptured membranes, and perform speculum checks. Interview revealed nurses are checked off during annual competency by their peers in performing a quality amnisure test and vaginal exams. Interview revealed RN #4 described the steps in the labor check as assigning the mother a room, putting mother on the monitor to assess if the baby's heartbeat and activity is appropriate for gestational age, vaginal exam and call the physician if there is no change in the cervix. Interview revealed the physicians, "trust our vaginal exams and trust that we have a good fetal strip." Interview revealed the physician gives the nurse discharge orders and the nurse provides the patient with discharge (D/C) instructions. Interview revealed the physician may say "it does not sound like they are in labor," but, "we do not have a D/C diagnosis at discharge, it is not part of the discussion with the physician."

Interview on 10/29/2015 at 1200 with Chief Nursing Officer (CNO) #1 revealed there was no available documentation in the medical record where Physician E certified that after a reasonable time of observation, Patient #20 was in false labor; and no available documentation of a medical diagnosis written by Physician E or verbally given by telephone to the L&D Nurse and documented in the medical record as of 10/29/2015.

3. Review on 10/29/2015 of current facility policy "EMTALA (EMERGENCY MEDICAL TREATMENT AND LABOR ACT): MEDICAL SCREENING, STABILIZATION, AND TRANSFER", Policy: 509, revised 12/2012, revealed "...III. DEFINITIONS ...D. Appropriate Medical Screening Examination ...The screening exam is performed by qualified medical personnel as designated by the medial staff bylaws. ...G. Labor ...A woman experiencing contractions is in true labor unless a physician, certified nurse midwife, or other qualified medical person (as defined in the medical staff bylaws) certifies that, after a reasonable time of observation, the woman is in false labor. ...IV. PROCEDURE: A. Patient Evaluation and Treatment ...3. The individual shall be evaluated by qualified medical personnel that have been designated by the hospital in its medical staff bylaws or its medical staff rules and regulations. ..."

Review on 10/28/2015 of Hospital A's current "Medical Staff Bylaws" dated 12/19/2013 and "Medical Staff Rules and Regulations" dated 04/11/2014 failed to reveal any available documentation of the definition or identification of the individual(s) who were determined qualified by the hospital bylaws or rules and regulations and who met the requirements of §482.55 who could con

Based on policy review, closed medical record reviews, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) and/or Labor and Delivery (L&D)physician failed to ensure an appropriate transfer; by failing to complete a written physician's certification for transfer documenting the medical benefits and increased risks associated with the transfer for the specific Emergency Medical Condition (EMC); and failed to ensure the written physician's certification was signed and/or dated and timed by the transferring physician to closely match the time of transfer for 4 of 4 sampled patients that were transferred with an EMC to other acute care hospitals (DED #13, #21, #3, and L&D #20).

The findings include:

Review on 10/28/2015 of current facility policy "EMTALA (EMERGENCY MEDICAL TREATMENT AND LABOR ACT): MEDICAL SCREENING, STABILIZATION, AND TRANSFER", Policy Number: 509, revised 12/2012, revealed "...II. PURPOSE AND APPLICABLE LAW: ...It is the policy of (Hospital A) to provide an appropriate medical screening examination, regardless of ability to pay, to persons requesting care or treatment on the hospital campus to determine the nature and extent of their injury, medical condition and/or pregnancy and to provide such additional care within the capabilities of the hospital and staff to stabilize the condition of the patient or to provide for an appropriate transfer. ...IV. PROCEDURE: A. Patient Evaluation and Treatment ...4. If it is determined that an emergency medical condition exists, (Hospital A) shall either: ...b. Appropriately transfer of the individual to another medical facility. EMTALA permits transfer of an unstable patient for only two reasons: medical indication and patient request. A medically indicated transfer is to a facility that can provide a higher level of care necessary to treat the patient's emergency medical condition that is not available at the transferring hospital. ...B. Transferring Physician and Facility 1. For a medically indicated transfer of an unstable patient, the hospital must: a. Certify that the benefits to the patient from transfer outweigh the risks. ...The transferring physician must certify, in writing, that 'based upon the information available at the time of transfer, the medial benefits reasonably expected from the provision of medical treatment at another facility outweigh the increased risks to the individual and, in the case of labor, to the unborn child from effecting transfer.' ....A physician should certify the transfer as medically indicated only when the patient is being transferred to a facility that has equipment or physician resources not available at the transferring hospital. ...".

1. Hospital A (transferring facility), closed DED record review on 10/28/2015 for Patient #13 revealed a 7 month old male patient presented to the DED via private transportation carried by parents on 08/10/2015 at 1200 with a chief complaint of "Altered Mental Status." Review revealed the patient was pivot triaged (Triage #1) by a Registered Nurse (RN) at 1203. Review of triage RN documentation revealed "parents state that they found child just prior not responsive. Infant not following gaze initially upon arrival in ED but is becoming more alert. Parents stating he had similar episode of [sic] Friday and was here in ED for possible seizure. Reports at that time they found him unresponsive and did cpr (cardiopulmonary resuscitation)." Review revealed the patient was assigned a priority level 2 (1-5 scale with 1 most severe and 5 least). Review revealed the patient was reassessed by a triage RN (Triage #2) at 1206. Review revealed "pt (patient) presented to the ED with parents c/o (complaints of) seizure like activity at home approximately 45 minutes prior to arrival. pt woke from his nap 'started staring off into space then started shaking and vomiting' pt is lethargic at this time per mom. pt tearful while getting rectal temp. (temperature) parents report that he was seen here for a possible seizure this previous Friday." Review of ED Nursing Assessment documentation by an RN at 1233 revealed, "Mother reports pt is a normally developed 7 mo (month) old, reports pt was seen here Friday after being found blue and not breathing. PTA (prior to arrival) today pt vomited x (times) 5, was breathing but unresponsive, pt will now awaken and cry, open eyes, behavior not age appropriate at this time." Review revealed at 1250, "Pt held in father's arm, began to tremor, generalized over body, facial twitching, drooling, seizure like activity. Dr. (Physician D) called into room to see pt, ordered 2 mg (milligrams) valium (Benzodiazepine - used to treat seizure disorders) PR (per rectum), ok to give liquid inj (injection) form per Dr. (Physician D). ...Seizure lasted approximately 2 minutes. Mouth suctioned with bulb syringe, minimal secretions. Pt remains on monitor, Dr. (Physician D) at bedside speaking with pt. [sic]." Review revealed at 1551, "pt has seizure activity. generalized shaking with bilateral eye deviation to right upper. pt turned on left lateral side for safety. suction present. administered PR valium as ordered by dr. (Physician D)." Review revealed at 1152, "seizing completed. pt remains on left lateral side for safety..." Review revealed at 1650, "seizure activity noted again. dr. (Physician D) at bedside. orders obtained for additional 0.25 IVP (intravenous push) ativan (Benzodiazepine - used to treat seizure disorders) by dr. (Physician D). given as ordered." Review revealed at 1701, "pt remains on left lateral side in bed for safety. pt awake. pupils checked and are equal and reactive to light." Review revealed at 1711, "Dr. (Physician D) at bedside to update parents on pending transfer." Review revealed at 1806, "EMTALA signed by parent." Review at 1815 revealed, "Transfer Documentation" with Accepting Facility: (Hospital C), Accepting Physician: (Physician L), Transferring Provider: (Physician D), Diagnosis: Seizures, and Transfer crew at bedside at 1815. Review revealed at 1826, "Patient discharged via Stretcher." Further review revealed "Pt leaving ED via (Ambulance Service #1) transport enroute to (Hospital C)."

Review of MSE documentation by Nurse Practitioner (NP) #1, revealed the patient was seen at 1210. Review revealed a chief complaint of "Altered Mental Status" and a stated complaint of "Possible Seizure." Review revealed "Notes: ...presents to ed for seizure like activity for 45 minutes. woke up from nap crying the [sic] was staring off in space off and on the [sic] would focus for a minute the [sic] stare off in space. projectile vomiting for 4 big amounts and 1 small amount. Parents [sic] he has been letargic [sic] the entire time. cries when BP (blood pressure) and temp done otherwise laying on shoulder eyes closed not moving around. ..." Review of MSE documentation by Physician D revealed the patient was seen at 1250. Review revealed a chief complaint of "Altered Mental Status" and a stated complaint of "Possible Seizure." Review revealed "Notes: Pt is 7 month 22 day old male who presents to ED secondary to possible seizure PTA today. Father states pt began 'shaking', staring off, and became unresponsive after waking up from nap 45 minutes PTA. Father states pt then became lethargic. Father denies fever, diarrhea, or rash. Father states pt was seen in ED Friday (8/7) secondary to being found cyanotic, and unresponsive by him. Pt was brought to ED for evaluation. (Hospital A) records show that pt had labs, CT (computed tomography) performed (Negative), then admitted for observation. Father states pt was discharged from (Hospital A) 8/8. Review revealed "GEN (General): Appears stated age. Patient is not awake. Parents holding the child most time. ...RESP (respirations): CTA (clear to auscultation) B/L (bilaterally), no wheezes, rales or rhonchi. Adequate Vt (tidal volume). CV (cardiovascular): RRR (regular rate rhythm) with no M/R/G (murmurs, rubs, gallops) MS (mental status): Non-rhythmic movement of extremities that are consistent with seizure activity. When not seizing there is no signs of trauma to the extremities. NEURO (neurological): Alert at times and looking apparent [sic]. He is nonverbal due to age. No obvious focal deficits but the exam is limited. CN (cranial nerves) 2-12 grossly intact. CGS [sic] (Glasgow coma scale) 15 (normal)." Review of re-evaluation revealed at 1630, "Another seizure noticed. This was not as strong as the other one I witnessed." Review revealed at 1709, "Talked with (Hospital C). Dr. (Physician L) will accept patient. Stated they can go higher doses on the Ativan even up to 1 mg (milligram) at a time. Will call me regarding the phenobarbital (barbiturate - used to treat seizure disorders) loading dose. ..." Review revealed at 1726 "Dr. (Physician M) called me about this child. She is peds neuro. Wants phenobarbital 20/kg (kilograms) over 10 minutes." Review revealed "Clinical Impression: Seizure" and "Condition: Fair." Review revealed "Disposition: (Hospital C)."

Review of a "PATIENT TRANSFER FORM (EMTALA)" completed for Patient #13 on 08/10/2015 revealed the following pre-printed on the form "PART I (To be completed by Physician) I hereby certify that based upon reasonable risks and benefits to the patient, and based upon the information available at the time of the patient's examination, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks, if any, to the individual's medical condition from effecting the transfer. The benefits relied upon for the transfer are: [check box left blank] Specialized Equipment at Receiving Facility [check box left blank] Specialized Services/Procedure at Receiving Facility [check box left blank] Continuity of Care Other __(line left blank)__. The risks of transfer are: [check box left blank] Transportation Risks which include traffic delays, accidents during transport, inclement weather, rough terrains or turbulence, limitations of equipment and personnel in transport [check box left blank] Deterioration in Patient Condition which includes a potential threat to the health and possible survival of the Patient Other__(line left blank)__." Further review revealed "Chief Complaint/Preliminary Diagnosis" with "Seizures" handwritten on a line. Review revealed "Reason for Transfer [check box left blank] Dialysis [check box left blank] Orthopedic Procedures [check box left blank] Neurosurgery Procedures [check box left blank] NICU (neonatal intensive care unit) [check box left blank] PICU (pediatric intensive care unit) [check box left blank] Interventional Cardiac Services [check box left blank] High Risk OB (obstetrical) [check box left blank] Trauma Care [check box left blank] Specialized MD Care [check box left blank] No ICU (intensive care unit) beds [check box left blank] Other [check box left blank] Specify__(line left blank)__." Review revealed "Facility Accepting Transfer" with (Hospital C) hand written on a line. Review revealed "Physician Accepting Transfer" with (Physician L) handwritten on a line. Review revealed "Transferring Physician's Signature" with Physician D's hand written signature on a line. Further review revealed the lines adjacent to the "Transferring Physician's Signature" for the date and time were left blank. Further review of the form revealed "PART III PATIENT CONSENT FOR TRANSFER (To be completed by the Patient) I understand that it is the opinion of the physician responsible for my care that the benefits of transfer outweigh the risks of transfer. I have been informed of the risk and benefits to transfer upon which this transfer is being made. I have considered the risks and benefits listed in Part I of this form and consent to transfer. ..." Review revealed the handwritten signature of the patient's father on the "Signature of Patient or Responsible Party" line dated 08/10/2015 at 1800. Review revealed the signature was witnessed by a RN. Review of the form and medical record failed to reveal any available documentation by the physician certifying the transfer indicating that the benefits and increased risks of transfer specific to the patient's emergency medical condition of Seizures were explained to the patient's parents. Further review revealed no available documentation of the date and time the transferring physician signed "Patient Transfer Form" (Physician Certification).

Hospital C (Recipient Facility) closed medical record review on 10/30/2015 for Patient #13 revealed the patient was an emergency admit to Bed WT215 on 08/10/2015 at 2018 with an admitting diagnosis of Seizures. The patient was discharged on 08/14/2015 at 1730 with a diagnosis of Seizure Disorder and Bilateral Occipital Infarctions. Review of a discharge summary dated 08/14/2015 at 1441 revealed "...Discharge Condition: Stable. ...Hospital Course including Consultants Input: ...presenting with new onset seizures during admission he was found to have non-hemorrhagic moderate-sized bilateral occipital lobe infarctions per MRI (magnetic resonance imaging). ..."

Telephone interview on 10/29/2015 at 1122 with Physician D revealed he had been a locums tenens (temporary substitute) physician for the hospital for approximately 4 years. Interview revealed he was the physician who performed the MSE on Patient #13 on 08/10/2015. Interview revealed he was the physician responsible for the patient's transfer to Hospital C. Interview revealed Hospital A has limited resources and has no pediatric ICU beds or pediatric neurologist. Interview revealed he talked to the parents about the transfer. Interview revealed he does not document specific risks and benefits of transfer in the medical record. Interview revealed he only documents on the transfer forms. Interview revealed "the nurse usually hands the forms to me to sign. They hand me 4-5 forms to sign in all." Interview revealed specific risks for Patient #13 included "seizure activity, decreased level of consciousness, deterioration, airway compromise." Interview revealed specific benefits of transfer included "Peds Neurologist, Peds ICU, increased monitoring." Interview revealed "usually the nurse checks the boxes on the form." Interview revealed "I just put my signature on the form." Interview revealed "I typically do not date and time the form." Interview confirmed Physician D failed to document the medical benefits and increased risks associated with the transfer for the specific EMC and condition of Patient #13 at the time of transfer and failed to sign, date and time the Patient Transfer Form (Physician Certification) to closely match the actual date and time of the patient's transfer.

Interview on 10/29/2015 at 1200 with Chief Nursing Officer (CNO) #1 revealed the standardized pre-printed risk and benefits check boxes on the Patient Transfer Form dated 08/10/2015 for Patient #13 were left blank. Further interview revealed the date and time of the transferring physician's signature was left blank. Interview revealed there was no available documentation in the medical record where Physician D documented the medical benefits and increased risks associated with the transfer for the specific EMC and condition of Patient #13 at the time of transfer and documented the date and time the Patient Transfer Form (Physician Certification) to closely match the actual date and time of the patient's transfer.

2. Hospital A (transferring facility), closed DED Labor and Delivery (L&D) record review on 10/28/2015 for Patient #20 revealed the patient presented to the L&D via wheelchair on 09/24/2015 at 2212 for "Cramping." Review revealed an EDC (estimated date of confinement) of 12/23/2015. Review revealed an EGA (estimated gestational age) of 27.1 weeks. Review of nursing documentation revealed the patient was triaged by a RN at 2308. Review revealed a chief complaint of "uterine cramping" and "dizziness." Review revealed contractions were irregular, onset 09/24/2015 at 1200. Review revealed pain was assessed as 0 (zero). Review revealed at 2330, contraction frequency was 2-4 per minute, duration 50-80 seconds, quality mild. Pain was reassessed as a 0 (zero). Review revealed "pt (patient) denies feeling cramping at this time." At 0000 (09/25/2015), contraction frequency 1.5-3 per minute, duration 50-80 seconds, quality mild. Review revealed pain was reassessed as 2 (0-5 scale - 0 pain free, 5 worst pain), pain presence intermittent, pain type cramping, and pain location abdomen. At 0006, "Notified Dr. (Physician B) of c/o (complaints of) dizziness and cramping. Pt (patient) ctx (contraction) pattern, FHT (fetal heart tones), ED Interventions. pt pain 2/5...". At 0030, contraction frequency 1.5-4 per minute, duration 50-80 seconds, quality mild. At 0100, contraction frequency 2-5 per minute, duration 50-90 seconds, quality mild. At 0130, contraction frequency 2-6 per minute, duration 60-80 seconds, quality mild. At 0200, contraction frequency 3-5 per minute, duration 50-70 seconds, quality mild. At 0219, "pt reports increased discomfort with contractions." At 0221, "Dr. (Physician B) updated on patient results. Dr. (Physician B) will come to unit to evaluate patient." At 0230, contraction frequency 2-4 per minute, duration 50-70 seconds, quality mild/moderate. At 0254, "Dr. (Physician B) at bedside." At 0300, contraction frequency 2-3 per minute, duration 50-70 seconds, quality mild. At 0302, "Dr. (Physician B) at bedside to discuss transferring patient to (Hospital B)." At 0311, "Discussed with [sic] POC (Plan of Care) with transfer. Patient agrees to go to (Hospital B) to transfer care. All questions answered (documented by a RN)." At 0330, contraction frequency 1.5-3 per minute, duration 50-180 seconds. At 0400, contraction frequency 3-5 per minute, duration 50-80 seconds, quality mild. At 0430, contraction frequency 2-7 per minute, duration 50-80 seconds, quality mild. At 0500, contraction frequency 3-4 per minute, duration 70-90 seconds, quality mild. At 0518, "(Ambulance Service #2) ambulance transport at bedside, report given, care relinquished." At 0524, "Pt off unit via stretcher by (Ambulance Service #2) ambulance transport for transport to (Hospital B)."

Review of MSE documentation by Physician B dated 09/25/2015 at 0315 revealed the patient was G (Gravida) 2, P (Para) 0 with EDC of 12/23/2015 and EGA of 27.2 weeks. Review revealed "cc (chief complaint) - dizziness, CTx's (contractions)." Review of "Physical Exam" revealed "Other: + (positive) mild fundal tenderness" and "Contractions: q1-4" (every 1-4 per minute)" and "SVE (sterile vaginal exam): cl/50/^ (closed/50% effaced/High) soft." Review revealed "U/S --> VTX (ultrasound - Vertex)." Review of "Diagnosis" revealed "IUP (intrauterine pregnancy) @ (at) 27.2 (weeks) with preterm CTX's (contractions), ? (questionable) early chorio (chorioamnionitis - inflammation of the fetal membranes due to a bacterial infection)." Review revealed "Plan: ...Transfer to (Hospital B) - Dr. (Physician N) accepting physician."

Review of a "PATIENT TRANSFER FORM (EMTALA)" completed for Patient #20 on 09/25/2015 revealed the following pre-printed on the form "PART I (To be completed by Physician) I hereby certify that based upon reasonable risks and benefits to the patient, and based upon the information available at the time of the patient's examination, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks, if any, to the individual's medical condition from effecting the transfer. The benefits relied upon for the transfer are: [check mark in box] Specialized Equipment at Receiving Facility [check mark in box] Specialized Services/Procedure at Receiving Facility [check mark in box] Continuity of Care Other __(line left blank)__. The risks of transfer are: [check mark in box] Transportation Risks which include traffic delays, accidents during transport, inclement weather, rough terrains or turbulence, limitations of equipment and personnel in transport [check mark in box] Deterioration in Patient Condition which includes a potential threat to the health and possible survival of the Patient Other__(line left blank)__." Further review revealed "Chief Complaint/Preliminary Diagnosis" with "Preterm Contractions @ 27+ (plus) wks (weeks)" handwritten on a line. Review revealed "Reason for Transfer....[check mark in box] NICU (neonatal intensive care unit)....[check mark in box] High Risk OB (obstetrical)... ." Review revealed "Facility Accepting Transfer" with (Hospital B) hand written on a line. Review revealed "Physician Accepting Transfer" with (Physician N) handwritten on a line. Review revealed "Transferring Physician's Signature" with Physician B's hand written signature on a line. Review revealed "Date" signed "09/25/2015 (handwritten on line)" and "Time" signed "0330 (handwritten on line)." Further review of the form revealed "PART III PATIENT CONSENT FOR TRANSFER (To be completed by the Patient) I understand that it is the opinion of the physician responsible for my care that the benefits of transfer outweigh the risks of transfer. I have been informed of the risk and benefits to transfer upon which this transfer is being made. I have considered the risks and benefits listed in Part I of this form and consent to transfer. ..." Review revealed the handwritten signature of the patient on the "Signature of Patient or Responsible Party" line dated 09/25/2015 at 0345. Review revealed the signature was witnessed by a RN. Review of the form and medical record failed to reveal any available documentation by the physician certifying the transfer indicating that the benefits and increased risks of transfer specific to the patient's emergency medical condition of Preterm Contractions at 27.2 weeks and questionable early chorioamnionitits were explained to the patient. Further review revealed the date and time (09/25/2015 at 0330) of the physician's certification for transfer DID NOT closely match the date and time (09/25/2015 at 0524) of the patient's transfer. Review revealed Physician B signed the "Patient Transfer Form" (Physician Certification) 114 minutes prior to Patient #20's departure from Hospital A's L&D unit for transfer to Hospital B.

Hospital B (Recipient Facility) closed medical record review on 10/30/2015 for Patient #20 revealed the patient was a direct admit to High Risk Antepartum Bed 3105-1 on 09/25/2015 at 0709 with an admitting diagnosis of Pre-Term Contractions. The patient was discharged on 09/26/2015. Review of physicians' progress notes dated 09/26/2015 at 0944 revealed "...PLAN: ...No current evidence of preterm labor. ..." and at 1206 revealed "Plan: ...Discharge home today."

Telephone interview on 10/29/2015 at 1045 with Physician B revealed she was on the medical staff of Hospital A. Interview revealed she had been on the medical staff for approximately 5.5 years. Interview revealed she was an OB/GYN (Obstetrical/Gynecology) physician. Interview revealed she was the attending physician who performed the MSE on Patient #20 on 09/25/2015 and transferred her to Hospital B. Interview revealed patients under 32 weeks are transferred and do not deliver at Hospital A. Interview revealed the patient was transferred due to pre-term contractions at 27+ weeks and questionable chorioamnionitits. Interview revealed the closest hospital to transfer the patient too was Hospital B. Interview revealed she arranged for the transfer. Interview revealed Hospital B had accepted the patient and had bed availability. Interview revealed the patient was transferred by ground ambulance. Interview revealed she completed the paperwork and signed the transfer form. Interview revealed she signs, dates and times the form "as soon as I get the ok and acceptance of patient information." Interview revealed the time of transfer depends on ambulance availability. Interview revealed "it can be as quick as 20 minutes and sometimes takes hours." Interview revealed if there is a delay in the time of transfer, she does not routinely go back and re-sign, re-date, and re-time the transfer form to closely match the actual time the patient is transferred from the L&D to the other hospital. Interview revealed she "lets the form stand." Interview revealed risk and benefits are usually explained to the patient and/or guardian by the physician. Interview revealed the nurses have the patient and/or guardian sign the transfer form. Interview revealed there was "no imminent delivery" but the patient was transferred for a "higher level of care." Interview revealed specific increased risks associated with the patient were "small risk of delivery of baby" and "abruption (of placenta)" and "becoming lightheaded and dizzy" and "health deterioration." Interview revealed specific benefits of transfer included "NICU availability, Ventilator management and maintenance, Staffing and Physicians' experience, equipment availability, and OB Services with increased support for mom." Interview revealed she does not routinely write specific risks and benefits related to the patient's emergency medical condition on the transfer form. Interview revealed "there are boxes to check, that are globally accepted so I just check them." Interview revealed "I usually put a check mark in the box, only." Interview confirmed Physician B failed to document the medical benefits and increased risks associated with the transfer for the specific EMC and condition of Patient #20 at the time of transfer and failed to sign, date and time the Patient Transfer Form (Physician Certification) to closely match the actual date and time of the patient's transfer.

Interview on 10/29/2015 at 1200 with CNO #1 revealed there was no available documentation in the medical record where Physician B documented the medical benefits and increased risks associated with the transfer for the specific EMC and condition of Patient #20 at the time of transfer and signed, dated and timed the Patient Transfer Form (Physician Certification) to closely match the actual date and time of the patient's transfer.


36216

3. Hospital A (transferring facility), closed DED record review on 10/28/2015 for Patient #21 revealed a 42 year old male patient presented to the DED via ambulance on 10/03/2015 at 0838 with chest pain. Review revealed the patient was Pivot triaged (Triage #1) by a Registered Nurse (RN) at 0839. Review of triage nurse documentation revealed, "Pt (patient) presents to ED with c/o (complaint of) CP (chest pain)/SOB (shortness of breath) x (times) 6 hrs (hours), pt reports he started feeling numbness and sinus pressure around midnight reports taking allegra (allergy medicine) at 0300 then again later this am [sic]. pt reports chest tightness that began at 0745. pt states that he thought he was having an allergic reaction to something. EMS (emergency medical services) reports that the patient went Asystolic (absence of heart beat) under their care, reports that they initiated chest compressions. the EKG (electrocardiogram) performed by EMS shows sinus pause (irregular heart beat) of approximately 3 seconds. patient is alert and oriented. pt is pale at this time, pt is profusely shaking stating tha [sic] the [sic] is not cold that he is having an allergic reaction." Review revealed the patient was assigned a priority level 2 (Emergency Severity Index 1-5, 1 most severe and 5 least severe). Review of MSE documentation by Physician C revealed,the patient was evaluated at 0830. Review revealed, "ED Cardiac - General Stated Complaint: Possible Allergic Reaction... Mode of arrival: Medic, Information source: Patient, Emergency Med (medical) Personnel...". Review revealed at 0843, "Notes: This 32-year-old male patient brought to the emergency room by EMS. ...Last night about midnight he noticed he had some numbness in his sinuses and took Allegra. He took an additional dose a 3 AM. He woke up this morning and reported that he told his wife that he was too nervous. He had tightness in his chest. He had some dry heaves. He felt very nervous. 911 was called. EMS arrived and found the patient with a normal sinus rhythm and ST elevation in V3 V4 (electrical views of the heart) probably early repolarization pattern. They gave the patient aspirin, Zofran (antiemetic) and nitroglycerin (vasodilator) and about 2 minutes later the patient lost consciousness and they [sic] unable to feel a pulse. They report the monitor showed a flat line rhythm, 15 compressions were administered before the patient woke up. They report the monitor then showed a pulse in the 30s that slowly increased to 40 and then 50. On arrival to the emergency room the patient still had some chest pressure, and he is shaking and shivering uncontrollably. He continues to seem to be very nervous. His past medical history is significant for high blood pressure and hyperlipidemia (high cholesterol). ...Review of physical exam revealed, General Appearance: alert, anxious; In Distress: mild. Respiratory status: no respiratory distress, breath sounds normal. Cardiovascular: regular rhythm, heart sounds normal to auscultation, no murmur. Review revealed, "Discharge- Discharge Clinical Impression: CHEST PAIN, Asystole Condition: stable, Disposition: ...(Hospital C)." Review revealed at 1355, Accepting facility (Hospital C), Accepting physician - (Physician J) Transferring provider -... (Physician C), Patient transported to (Hospital C) via EMS.

Review of a "PATIENT TRANSFER FORM (EMTALA)" completed for Patient #21 on 10/03/2015 revealed the following pre-printed on the form "PART I (To be completed by Physician) I hereby certify that based upon reasonable risks and benefits to the patient, and based upon the information available at the time of the patient's examination, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks, if any, to the individual's medical condition from effecting the transfer. The benefits relied upon for the transfer are: [check box left blank] Specialized Equipment at Receiving Facility [check box marked] Specialized Services/Procedure at Receiving Facility [check box left blank] Continuity of Care Other __(line left blank)__. The risks of transfer are: [check box marked] Transportation Risks which include traffic delays, accidents during transport, inclement weather, rough terrains or turbulence, limitations of equipment and personnel in transport [check box marked] Deterioration in Patient Condition which includes a potential threat to the health and possible survival of the Patient Other__(line left blank)__." Further review revealed "Chief Complaint/Preliminary Diagnosis" with "Chest pain, Asystole" handwritten on a line. Review revealed "Reason for Transfer [check box left blank] Dialysis [check box left blank] Orthopedic Procedures [check box left blank] Neurosurgery Procedures [check box left blank] NICU (neonatal intensive care unit) [check box left blank] PICU (pediatric intensive care unit) [check box left blank] Interventional Cardiac Services [check box left blank] High Risk OB (obstetrical) [check box left blank] Trauma Care [check box marked] Specialized MD Care [check box left blank] No ICU (intensive care unit) beds [check box left blank] Other [check box left blank] Specify__(line left blank)__." Review revealed "Facility Accepting Transfer" with (Hospital C) hand written on a line. Review revealed "Physician Accepting Transfer" with (Physician J) handwritten on a line. Review revealed "Transferring Physician's Signature" with Physician C's name handwritten in print on the line in the same handwriting as the nurse (RN #9) who completed the Part II Transfer Information section of the form. Review failed to reveal the handwritten signature of Physician C on the "Transferring Physician's Signature" line. Further review revealed the lines adjacent to the "Transferring Physician's Signature" for the date and time were filled in with a different handwriting than RN #9. Further review of the form revealed "PART III PATIENT CONSENT FOR TRANSFER (To be completed by the Patient) I understand that it is the opinion of the physician responsible for my care that the benefits of transfer outweigh the risks of transfer. I have been informed of