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Based on review of recorded video footage of Patients 1 and 2, interviews, review of documentation in 10 of 30 patients who presented to the hospital for emergency services (Patients 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12), review of the central log, and review of policies and procedures, it was determined that the hospital failed to fully develop and implement its EMTALA policies and procedures.

Findings include:

1. Refer to findings identified under Tag A2406, CFR 489.24(a) and (c) which reflects the hospital's failure to enforce its EMTALA policies and procedures related to the provision of MSEs for Patients 1 and 2.

2. Refer to the findings identified under Tag A2405, CFR 489.20(r)(3), which reflects the hospital's failure to enforce its EMTALA policies and procedures related to the central log, including for Patients 1, 2, and 3.

3. Refer to the findings identified under Tag A2409, CFR 489.24(e)(1)-(2), which reflects the hospital's failure to enforce its EMTALA policies and procedures related to the provision of a summary of patient specific risks of transfer for Patients 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12.

Based on review of recorded video footage of Patients 1 and 2, interviews, review of the central log, review of documentation in 1 of 1 medical records of a patient for whom the central log reflected was admitted (Patient 3), and review of policies and procedures and other documents, it was determined the hospital failed to fully develop and enforce its EMTALA policies and procedures to ensure maintenance of a central log which contained complete and accurate information about each patient who presented to the hospital for emergency services as follows:
* Not all patients who presented to the hospital were entered on the log;
* The log contained numerous disposition omissions.
* The log inaccurately reflected that Patient 3 was admitted to SAMCO, however he/she was transferred to another hospital.

Findings include:

1. Review of the policy and procedure titled "Treatment and Transfer of Individuals Who Request Medical Services (EMTALA-Emergency Medical Treatment and Active Labor Act)" dated 10/17/2013 was reviewed and reflected "A central log must list each individual seeking or in need of emergency services who comes to the Hospital...must include an indication whether the individual did not consent to treatment or transfer, or was transferred, admitted and treated, stabilized and transferred, or discharged...A central log must include the name of the individual who comes to the hospital and makes it clear that the medical condition is not an emergency...that the individual does not have an emergency medical condition."

2. Review of the ED central log revealed Patient 3 presented to the ED on 12/30/2016. His/Her disposition was recorded as "Admitted as inpatient." However, review of the patient's record reflected the patient was transferred from the ED to SAMCB on 12/31/2016. During an interview while reviewing the central log the ED Manager confirmed that Patient 3 was not admitted, but transferred.

3. Review of the ED central log for the time period between 11/01/2016 through 03/08/2017 reflected a total of 4850 patients. The disposition for approximately 583 of those patients was blank.

During an interview with the ED Manager on 03/08/2017 at 1525 he/she confirmed there were many blank spaces in the log under the disposition column.

4. Refer to the findings identified under Tag 2406 CFR 489.24(a) and (c) that reflects that Patient 1 and 2 who presented to the hospital for ED services were not entered on the central log.

Based on interviews, observation of recorded video footage, review of hospital documentation about 2 of 2 patients who presented to SAMCO's ED who were not allowed entry into the building (Patients 1 and 2), review of policies and procedures, and other documents, it was determined the hospital failed to enforce its EMTALA policies and procedures to ensure that all patients who presented to the hospital were provided an MSE. Patients 1 and 2 were turned away from the ED by security during a "Code Secure" or lockdown situation.

Findings include:

1. During an interview with the VPO and ED Manager on 03/08/2017 at 1518 they reported that 2 patients were turned away from the ED by security personnel on 02/25/2017 and that video footage showed the event. They also indicated that the hospital investigated the event and had already begun corrective actions. At that time a written summary of the event was provided and reviewed. It reflected additional confirmation of the events of 02/25/2017 where Patients 1 and 2 were not permitted access to the hospital.

2. On 03/08/2017 at 1600, with the VPO and Security Manager, review of the video footage recorded that was dated and time-stamped 02/25/2017 at 2338 revealed an adult carrying a small child (identified as Patient 1 by the VPO) approaching the ED doors. A SAMCO security officer was observed conversing briefly with the adult and child. The adult then turned and walked back out to the parking lot with the child and got into a vehicle. A short time later the car was observed leaving the facility parking area.

During continuing review of video footage, that was dated and time-stamped 02/26/2017 at 0022, two adults (one of which was identified as Patient 2) were observed to walk from the parking lot and approached the entrance of the ED. A security officer was observed walking towards the adults into the parking lot and briefly conversed with the two adults. The adults were observed walking back to the parking lot and got into a vehicle that left approximately 1 minute later.

3. Review of the ED central log revealed no entries for Patients 1 and 2 on 02/25/2017 and 02/26/2017.

4. A document dated 03/03/2017 titled "Friday Update" reflected "Important!!! EMTALA & 'Code Secure' If a 'Code Secure' is called overhead this should never prevent us from accepting a patient that comes to us for medical care during the 'Code Secure.' The document was signed by the ED Manager.

During an interview with the ED Manager on 03/10/2017 at 0900 he/she stated the document was sent out to everyone in the department in response to the EMTALA event that occurred on 02/25/2017.

Based on interviews, review of documentation in 10 of 16 medical records of patients who were transferred from the ED (Patients 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12), review of medical staff bylaws, and policies and procedures, it was determined the hospital failed to fully develop and enforce its EMTALA policies and procedures to ensure that appropriate transfers of patients with EMCs were conducted. The physician transfer certification did not contain a summary of the patient specific risks of transfer upon which it was based as required by section (1)(B) of this CFR.

Findings include:

1. Review of the medical record of Patient 4, a two year-old, reflected he/she arrived at SAMCO carried by a parent on 01/03/2017 at 1710 with a complaint of SOB, stridor, rapid respirations, oxygen saturation of 94% and appeared in "moderate distress." The record reflected the patient received respiratory treatments and a chest x-ray. The record reflected the results of the x-ray as: "Findings consistent with bronchopneumonia somewhat asymmetrically greater on the left than the right." It was determined by the physician the patient would require pediatric services not available at SAMCO and arrangements were made to transfer to SAMCB.

Review of the Interhospital Transfer Record for Patient 4 revealed that the form did not include a summary of the patient's risks of transfer. There was no place on the form to elicit information regarding patient specific risks. Nor was patient risk information documented elsewhere in the medical record. The form reflected the patient was transferred from the ED on 01/03/2017 at 2003.

2. Review of the medical record for Patient 12 reflected he/she arrived via ambulance as a trauma activation to SAMCO on 03/02/2017 at 2244 with complaint of physical assault. The record reflected the patient sustained bilateral open mandible fractures, a hyoid fracture, and had airway compromise. It was determined by the physician the patient required a trauma transfer to SAMCB.

Review of the Interhospital Transfer Record for Patient 12 revealed a section titled "Physician Certification," in which the physician checked a box next to the following statement: Higher level of care required. Based on patient's condition at this time, I certify that the expected medical benefits to the patient from the provision of appropriate medical treatment at the facility identified below outweigh the increased risks to this patient...from the transfer." However, the form did not include a summary of the patient's risks of transfer. There was no place on the form to elicit information regarding patient specific risks. Nor was patient risk information documented elsewhere in the medical record. The patient was transferred from the ED on 03/03/2017 at 0010.

3. Review of medical records for Patients 3, 5, 6, 7, 8, 9, 10, and 11 reflected similar findings.

4. Review of the policy titled: "Treatment and Transfer of Individuals Who Request Medical Services (EMTALA-Emergency Medical Treatment and Active Labor Act)," dated "10/17/2013," reflected the following: "The individual may be transferred if a physician or, should a physician not physically be present at the time of the transfer, a Qualified Medical Person in consultation with a physician, has documented on the 'Physician Certification' section of Exhibit A that the medical benefits expected from transfer outweigh the risks..." There was no other language in the policy that stipulated the certification contain a summary of patient risks of transfer.

Review of a document titled "Bylaws Of The Medical Staff Of Saint Alphonsus Medical Center-Ontario (including rules and regulations)," date revised "03/10/16" contained a section titled "Use of Registered Nurses, Nurse Practitioners and Physician Assistants to Certify Transfers Under EMTALA." There was no language in that section or elsewhere in the bylaws that addressed all elements of an appropriate transfer, including that a summary of patient risks of transfer be contained in the physician certification.

5. An interview with the ED Manager during record review on 03/09/2017 beginning at 1000 confirmed neither the transfer records nor medical records for Patients 3-12 included any patient specific summaries of risks.