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Based on interview and record review, the hospital failed to abide by the provider's agreement that required a hospital to comply with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements, citing 4 of 20 patients (Patients #1, #2, #4 and #5) that presented in the emergency department from July 01, 2017 through January 24, 2018.

Cross Refer to Tags 2406 and 2409.

Based on record review and interview the hospital failed to ensure 3 of 20 patients (Patients #2, #4, and #5) received an appropriate medical screening exam (MSE) when presenting to the hospital.

Findings:

Review of the central logs on the afternoon of 01/23/18 indicated the following patients presented to the hospital with an EMC (Emergency Medical Condition) and were not provided with an MSE:

1. Patient #2 was a 14-year-old female who arrived by car on 10/24/17 with an EMC. The patient had attempted suicide and had recent panic attacks. A review of her medical record reflected no documentation of an MSE was provided.

2. Patient #5 was a 12-year-old female who arrived by car on 12/08/17 with an EMC. Patient #5 had suicidal ideation's. A review of her medical record reflected no documentation of an MSE was provided.

3. Patient #4 was a 23-year-old female who arrived by car on 12/27/17 with an EMC. The patient reported that she had suicidal ideation's. A review of her medical record reflected no documentation of an MSE was provided.

During an interview with Physician #9 on 01/24/18 at 2:30 PM he looked at the medical records of Patients #2, #4, and #5. He confirmed there was no documentation of a medical screening exam in their medical records. He said the medical screening exams were done, but were not documented.

A review of the hospital's EMTALA policy with a review date of 04/2017 reflected the following pages 1-2: " ...EMTALA is triggered if a patient presents on the hospital property and requests an examination or treatment for an emergency condition or if a reasonable person would believe he or she may be suffering from an emergency. This includes the request for an examination or treatment by the mental health authority, sheriff's office, or local police department ... A medical screen will be completed to determine if an emergency medical condition exits ... A suicidal/homicidal assessment will be completed to determine if an emergency psychiatric condition exists ...

Based on record review and interview, it was determined the facility failed to ensure the receiving hospitals had accepted the transfers of 4 of 4 patients (Patient #1, #2, #4, and #5), and had agreed to provide appropriate medical treatment for them.

Findings:

Review of the central logs on the afternoon of 01/23/18 indicated the following patients presented to the hospital with an EMC (Emergency Medical Condition) and were transferred for medical clearance to a hospital. The transferring hospital could not provide documentation of the receiving hospitals acceptance of the transfers of the following patients, and their agreement to provide appropriate medical treatment for them:

1. Patient #1 arrived at the hospital on 12/25/17 at 6:00 PM and was transferred to a local hospital on 12/25/17 at 6:55 PM for medical clearance. There was no documentation of communication with the receiving hospital prior to his transfer.

2. Patient #2 was a 14-year-old female who arrived by car on 10/24/17 with an EMC. The patient had attempted suicide and had recent panic attacks. There was no indication to what hospital the patient was transferred to for medical clearance.

3. Patient #5 was a 12-year-old female who arrived by car on 12/08/17 with an EMC. Patient #5 had suicidal ideation's. There was no indication to what hospital the patient was transferred to for medical clearance.

4. Patient #4 was a 23-year-old female who arrived by car on 12/27/17 with an EMC. The patient reported that she had suicidal ideation's. A review of her medical record reflected no indication to what hospital the patient was transferred to for medical clearance.

During an interview on 01/23/18 at 2:35 PM with Personnel #4 he said when a patient came in with an emergency medical condition (EMC), the physician would perform a medical screening exam (MSE). The physician made the decision to transfer the patient or not to a local ED (emergency department). Personnel #4 said it was an issue in arranging for transportation, it could take from 1-3 hours, and that didn't include the time for a nurse to nurse and a doctor to doctor report. Usually 911 was called to transfer the patient.

During an interview on 01/23/18 at 2:50 PM with Personnel #2 she reviewed Patient #1's medical record and confirmed there was no documentation of contact with a hospital prior to the patient's transfer.

During an interview on 01/23/18 at 3:31 PM with Personnel #3 she said on the night of 12/25/17 a police officer brought in Patient #1. He had an Emergency Detention warrant for the patient. The intake clerk took Patient #1's vital signs and placed him in a room behind locked doors. The patient had a medical screening exam, and the physician recommended that the patient be medically cleared before admitting the patient. Personnel #3 told the police officer that the physician wanted Patient #1 to have a medical clearance at an ED, and the police officer needed to take the patient to an ED or follow an ambulance. The police officer got angry and he went outside and made a phone call. He then came back in and got Patient #1 and escorted him outside, left him, and drove off. Personnel #3 talked to Patient #1 and he said he wanted help. He requested that she call 911 and have him transferred to an ED for medical clearance. 911 was called and the patient willingly went out for medical clearance. He returned later that night and was admitted to the hospital. Personnel #3 confirmed she did not contact any hospital prior to the patient's transfer.

During a telephone interview on 01/24/18 at 12:30 PM with Personnel #6 she said she was working the night of 12/25/17 when Patient #1 came to the hospital. She said she really didn't know what happened. She saw the patient and the police officer and introduced herself. She confirmed she did not contact the receiving hospital before Patient #1 was transferred for medical clearance.

During a telephone interview on 01/24/18 at 2:03 PM with Physician #5 she said Patient #1 was medically stable for transfer. She wanted the patient transferred to an ED for lab work. It would have taken too long to get lab results if the patient had stayed at the hospital. Patient #1 had 2 grand mal seizures the day before while on anti-seizure medication and she wanted to make sure his electrolytes were okay. Physician #5 said she explained the reasons for the transfer to the patient and he agreed. She confirmed she had not documented the conversation. Physician #5 did not contact anyone at the receiving hospital before the patient's transfer. She said she had received EMTALA training.

During an interview with Physician #9 on 01/24/18 at 2:30 PM he looked at the medical records of Patients #2, #4, and #5. He confirmed there was no documentation of communication with a receiving hospital in their medical records. He said when the hospital first opened they followed the EMTALA requirements. The ED physicians at other hospitals started saying to him and other staff to stop calling them and just send the patients. It was as if they didn't have time to talk. When 911 was called the paramedics took the patients where they wanted to take them, not where staff requested the patient be taken. It was not possible to get permission from a hospital before they were taken by the ambulance, because it was unknown where they would be taking them. If a patient with an emergency medical condition had an ED (Emergency Detention) and needed medical clearance, 911 would have been called unless the police officer transferred them.

A review of the hospital's EMTALA policy with a review date of 04/2017 reflected the following pages 1-2: " ...EMTALA is triggered if a patient presents on the hospital property and requests an examination or treatment for an emergency condition or if a reasonable person would believe he or she may be suffering from an emergency. This includes the request for an examination or treatment by the mental health authority, sheriff's office, or local police department ... If the patient is suicidal or homicidal and cannot be treated at our facility, the Hospital must implement the appropriate transfer by doing the following... Call the hospitals located in the community that can care for the patient and find an accepting hospital ... If there is not a hospital able/willing to accept the patient for treatment and transfer, the Hospital is responsible to provide treatment for the patient ..."