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UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER 2315 STOCKTON BOULEVARD SACRAMENTO, CA 95817 Feb. 16, 2012
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on observation, interview and record review, the hospital failed to comply with CFR 489.24, the EMTALA requirements when there was no evidence of:

a. Appropriate Medical Screening Exams (MSE) to determine the presence of an emergent medical condition (EMC) and;

b. Appropriate transfer documents.

c. Appropriate posting of signs.

Findings:


1. The facility failed to provide an appropriate Medical Screening Exam (MSE) to determine whether an emergency medical condition existed for 20 of 20 patients who presented to the Emergency Department (ED) between 10/3/11 and 1/23/12. (Refer to A2406)


2. Four of seven sampled patients who were transferred from the ED to another acute care facility had missing or incomplete transfer documentation. ( Refer to A2409)

3. The facilityn failed to post EMTALA (Emergency Medical Treatment and Active Labor Act) rights information in locations likely to be seen by all patients arriving for emergency obstetrical care (Refer to A2402).
VIOLATION: POSTING OF SIGNS Tag No: A2402
Based on observation, interview and document review, the GACH (General Acute Care Hospital) failed to post EMTALA (Emergency Medical Treatment and Active Labor Act) rights information in locations likely to be seen by all patients arriving for emergency obstetrical care.

Findings:

On 2/13/12 at 12:26 p.m., observations made during the Initial Tour of the Birthing Suites revealed no signage containing all of the four required EMTALA posting statements in the lobby, near the intake check-in window or in the Antepartum (prior to birth) Testing area.

In a concurrent interview, ADON and NM2 stated obstetrical patients seeking emergency treatment would enter the lobby, check in at the intake window and subsequently be examined in Antepartum Testing or a birthing suite. NM2 identified a hallway area across from the intake window and stated, "This is where we have our postings."

Review of the GACH's "Emergency Medical Treatment and Active Labor Act (EMTALA)" policy, revised 12/28/11, reflected, "Signs shall be conspicuously posted in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas such as entrances, admitting areas and waiting rooms in ambulatory clinics. This signage shall provide, at a minimum, the following...Specific rights of patients with emergency medical conditions and women in labor...."
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to provide an appropriate Medical Screening Exam (MSE) to determine whether an emergency medical condition existed for 20 of 20 patients who presented to the Emergency Department (ED) between 10/3/11 and 1/23/12.

Findings:

1. Patient 14 was triaged as Category I (Red) (a condition defined by the ED as life threatening, requiring aggressive, immediate interventions) was placed on a gurney in the hallway and delayed in receiving a MSE.

In review of facility Policy ID: XII-70 titled Medical Screening Exam and Triage-Adult and Pediatric, revised 07/12/2010, Page 2, Triage Categories, there was stipulation that after the initial MSE had been completed, the nurse would assign a triage category to the patient using the five level triage acuity scale adopted by the ED. The categories were defined as:

i) Category 1: "Red" Conditions that are threats to life or limb or vision (or imminent risk of deterioration) requiring aggressive, immediate interventions. (Crisis or Resuscitative)

ii) Category II: "Orange" Conditions that present a potential life or limb-threatening emergency or patients who present with other acute illnesses or injuries and significant risk factors that could lead to a life or limb. (Emergent)

iii) Category III: "Yellow" Conditions where life and limb is not an immediate threat to well-being, but has the potential to develop into a serious problem requiring emergency intervention if treatment is not expedient. The patient's condition is stable, but treatment should be provided as soon as possible. (Urgent)

iv) Category IV: "Green" Conditions that are at low risk for deterioration while the patient is waiting. Significant complications from the illness or injury will not likely result if treatment is delayed.

v) Category V: "Blue" A patient for which the MSE has excluded an emergent medical condition. (Non-Emergent)


a) Patient 14, a 51 year old, (MDS) dated [DATE] at 5:46 p.m. and was triaged as a Level 1 (Red) (a condition defined by the ED as life threatening, requiring aggressive, immediate interventions). The ED Triage Note dated 11/4/11 at 5:51 p.m. indicated Patient 14 wanted "clearance" for admittance to an Acute Psychiatric Hospital (APH) because he felt that someone was trying to poison him and he was hearing voices telling him to overdose on medication. Patient 14 was placed in a hallway bed at 5:54 p.m., and the medical record had no documentation indicating Patient 14 had contact with a nurse or a physician after triage. Patient 14's medical record indicated he was called three times between 10:35 p.m. and 11:11 p.m., and was designated Left Without Being Seen (LWBT) at 11:12 p.m.

In an interview with a triage nurse (TN1) on 1/13/12 at 10:15 a.m., she stated she had not had any training for triage other than "orienting" with another nurse. She stated the nurses orient for "however long they think you need to be". When asked how the assigned triage level was determined, TN1 stated she looked at the history, vital signs and chief complaint and used her judgement to make the decision. TN1 described the "red" category as "the most critical", "the ones you want to get in as soon as possible", "the most unstable".

In an interview with TN2 on 1/13/12 at 10:30 a.m., she stated the computerized medical record system recommended a "best practice" level of acuity for the chief complaint entered by the nurse. TN2 demonstrated this by entering the chief complaint on the computer as chest pain and pointed out the Best Practice recommendation was Level 1 (Red). She demonstrated this again for the chief complaint Assaultive or Suicidal Behavior and pointed out the Best Practice recommended of Level 2 (Orange). When asked to review the triage level of random patients who had presented to the ED earlier that day, TN2 acknowledged that two of the four patients who presented for suicidal ideations had been triaged at a level lower than the recommended best practice (Level 3 rather than Level 2).

In an interview with TN3 on 1/14/12 at 8 a.m., he stated he used the "best practice" recommendations to assist him in assigning the level of acuity. TN3 stated he would place patients at the recommended best practice or a higher level if his assessment indicated. TN3 stated he would never place a patient at a lower than recommended acuity.

In an interview with the Nurse Manager (NM1), the Assistant Nurse Manager (AM1), the Chief of Staff (COS), who was the ED Vice Chair, and the ED Nurse Educator (NE) (the Team) on 1/15/12 at 8:45 a.m., they described the triage process. The Team acknowledged there were inconsistent practices in assigning acuities and that the level of acuity did not drive the timing of re-assessments or the MSE by the physician. The Team stated patients at any level of acuity could be placed on gurneys in the hallway until an ED room was available. The Team further revealed patients on gurneys in the hallway may be of a higher priority for being placed in a room, some may be psychiatric patients who needed closer observation and others might have arrived by ambulance and were waiting for a room. NM1 acknowledged patients in the hallway were "eyeballed" by the Internal Triage Nurse, but were not assigned to a nurse or a physician until they were placed in an ED room. The Team agreed that this was why there was minimal documentation in the medical record prior to placement in a room and may also account for the number of patients who left from hallway gurneys without being seen by the physician.

2. Five of 21 patients (1, 4, 5, 14, 20) who presented with psychiatric complaints did not receive an MSE by the physician.

In review of facility Policy ID: X!!-70 titled Medical Screening Exam and Triage-Adult and Pediatric, revised 07/12/2010, Page 2, there was stipulation "Categories I through IV need a more detailed MSE in the Emergency Department by an MD or NP/PA."

a) Patient 1, a [AGE] year old homeless male, (MDS) dated [DATE] at 1:43 a.m. with a complaint he "feels like hurting somebody" and was "stressed at this time". The triage nurse documented Patient 1's complaint as "delusional/hallucinating". The triage nurse assigned Patient 1 as a Level 4 (Green) (Non-Emergent) and Patient 1 was placed in a hallway bed in the ED. There was no nurse or physician assigned to see or further assess Patient 1 at that time.

Patient 1 was seen by a Licensed Clinical Social Worker (LCSW) at 3:42 a.m. The LCSW documented Patient 1 denied having active suicidal or homicidal ideations at that time. The LCSW noted Patient 1 exhibited anxiety as evidenced by "pacing, rapid speech, frequent hand gestures and repetitive statements" but "does not meet criteria for 5150 [Involuntary Hold] detainment". Patient 1 was discharged from the computerized medical record system at 6:23 a.m. There was no evidence Patient 1 had been seen by a physician during the stay in the ED.

In review of Patient 1's medical record, there was no documentation of any nursing or physician assessments after the initial triage at 1:45 a.m. until a note at 6:23 a.m. which documented "Cleared by PES" (PES = Psychiatric Emergency Services).

In an interview with NM1 on 2/13/12 at 11 a.m., she stated patients who present to the ED with a psychiatric complaint were routinely placed in a hallway gurney in the ED where they could be observed more closely than in the waiting room. NM1 acknowledged patients may wait several hours in the hallway and were not assigned to a nurse or a physician until they were placed in a room. NM1 further acknowledged that patients at any triage level may be placed in the hallway. NM1 acknowledged Patient 1 had not been seen by a physician.

In an interview with a LCSW1 on 2/16/12 at 8:35 a.m., she acknowledged she was the Social Worker assigned to Patient 1. LCSW1 stated she did a "full PES evaluation" of Patient 1 in the hallway near the Internal Triage area. LCSW1 stated Patient 1 did not meet the criteria for an Involuntary Hold. LCSW1 stated Patient 1 had requested resource information for housing. LCSW1 stated she was unable to find housing and told Patient 1 he could sleep in the lobby until morning when he could call his parole officer for direction. LCSW1 stated she told the nurse she had finished with her assessment and to call her when Patient 1 was ready to go to the lobby. Shortly thereafter, LCSW1 stated she was paged and she returned to Patient 1 and escorted him to the lobby. She was unaware Patient 1 had not been seen by the physician. LCSW1 further stated patients would be seen by a physician if they were placed in a room, but did not know what happened with patients who remained in the hallway. When asked if she would tell a patient they would be seen by a physician, LCSW1 responded "I don't know if there is a medical issue so I avoid any discussion of the medical determination or tell them that they will see a physician".

In an interview with the Social Services Supervisor (SSS) and the Social Services Manager (SSM) on 1/14/12 at 11 a.m., the SSM stated "All patients need to be medically cleared, even if [they only have] psychiatric symptoms".

b) Patient 14, a 51 year old, described in #1 above, had been triaged as a Level 1 (Red) for suicidal ideations on 11/4/11 at 5:46 p.m. and had placed on a hallway gurney in the ED. Patient 14 was not assigned to a nurse or physician and there was no evidence of re-assessments or monitoring. Patient 14 was seen by a LCSW at 7:43 p.m. and documentation indicated Patient 14 did not meet the criteria for an involuntary hold. The following was noted: " . . .Told patient that if he begins to feel bad, he should come back to the ER . . . The on-call [community mental health program social worker] came to the ER and together a safety plan was arranged . . . Patient may be discharged when medically ready . . .". There was no further documentation of any observations, monitoring or interventions present in the medical record. There was no evidence Patient 14 had been seen by a physician. Patient 14's chart indicated he LWBT at 11:12 p.m.

In a concurrent interview and record review with NM1 on 2/15/12 at 1:30 p.m., she stated the LCSWs may be giving patients the impression they can go home after their evaluation was completed. She stated the LCSW should report to the nurse or physician when the evaluation was completed and the patient was ready to be seen by the physician before discharge.

c) Patient 4, a [AGE] year old (MDS) dated [DATE] with a psychiatric complaint and was triaged at 6:34 p.m. as a Level 4 (Green). Patient 4 was transferred to a hallway bed at 6:36 p.m. Patient 4 was never assigned to a nurse or a physician and there was no evidence of any re-assessment or monitoring after triage. Patient 4 was seen by the LCSW at 10:24 p.m. who documented: "[Patient 4] comes in tonight . . . reports that besides her struggles from her recent trauma, she is 'doing well'. She denies any suicidal or homicidal ideation . . . thoughts are clear . . . is going to call her [local mental health group] Counselor and see if the Counselor will give her a ride home." Patient 4 was transferred back to the waiting room at 10:20 p.m. Patient 4 was designated as LWBT at 11:46 p.m.

In a concurrent interview and review of Patient 4's clinical record with NM1, on 2/15/12 at 1:45 p.m., she stated it looked as if the LCSW discharged the patient.

d) Patient 20, a 33 year old, (MDS) dated [DATE] at 5:43 p.m. with a history of bipolar and paranoid schizophrenia. The triage nurse documented Patient 20 was "Experiencing paranoia . . . cooperative [sic] want to talk to a psych person". Patient 20 was triaged as a Level 3 (Yellow) and placed in a hallway gurney at 6:26 p.m. There was no nurse or physician assigned to Patient 20. There was no evidence of any re-assessment or monitoring after triage. Patient 20 was seen by the LCSW, who documented in a note at 8:23 p.m. that Patient 20 did not meet the criteria for an involuntary hold. The following was noted: "Provided pt [patient] with MHZ [mental health] resource list and discussed and encouraged private psychotherapy . . . Pt has appointment at the end of this week with a new psychiatrist . . . agreed to follow up with seeking outpatient psychotherapeutic support this week . . .discussed a clear safety plan that pt was able to agree to . . . Pt does not at this time meet criteria for 5150 [involuntary hold] and is discharged to his own care." Patient 20 was discharged in the clinical record at 7:20 p.m. and was designated LWBT.

In an interview with LCSW2 on 2/15/12 at 2:15 p.m., she stated Patient 20 did not have any medical complaints and the psychological issues were worked through. She stated she asked Patient 20 if he wanted to be seen by the physician and Patient 20 declined.

e) Patient 5, a 67 year old, with hallucinations (hearing or seeing things which weren't there), was brought to the ED at 2:03 p.m. on 2/3/12 by law enforcement who requested a psychiatric evaluation. Patient 5 had a history of bipolar and post-traumatic stress disorders. Patient 5 was triaged as a Level 3 (Yellow) and placed on an interior ED hallway gurney at 2:12 p.m. Patient 5 was never assigned to a nurse or physician and there was no evidence of any re-assessment or monitoring after triage. The LCSW completed an evaluation at 3:34 p.m. and determined Patient 5 did not meet criteria for an involuntary psychiatric hold. The LCSW documented Patient 5 declined to see a physician and was given a bus pass and escorted to the bus stop by a volunteer. There was no evidence the LCSW had notified a nurse or physician that Patient 5 had declined to see the physician. Patient 5 was discharged from the medical record system at 9:37 p.m.

In an interview with the SSS on 2/16/12 at 10:50 a.m., she stated she was unsure of whose responsibility it was to let the psychiatric patients know they needed to be seen by the physician before leaving the ED. During the same interview, the SSM stated the psychiatric patients may believe they got what they needed [from the LCSW] and leave before seeing the physician.

In review of a facility Policy ID: 1150 titled Acute Mental Health Service Requiring Medical Clearance and/or Treatment, revised 04/06/2009, Page 4, C., 2. there was no reference to a medical screening examination for patients who presented themselves to the ED with a psychiatric complaint or request for a psychiatric evaluation and were not placed on an Involuntary Hold (51-50).

3. Twenty one of 21 patients who presented to the ED were triaged by nurses who had no evidence the medical staff had determined them to be qualified (OB) and/or completed the required competencies (ED).

a. In an Initial Tour of the ED on 1/23/12 at 11:20 a.m., NM1 stated approximately 80 nurses had been trained to initiate the MSE in triage and functioned under standardized procedures approved by the Medical Staff. In a concurrent interview with the COS, he stated ED nurses trained to initiate the MSE in triage were able to order interventions using the standardized procedures. These interventions included lab tests, x-rays, medications and electrocardiograms (a test to measure the electrical activity of the heart), which would expedite the diagnosis and treatment of patients presenting to the ED.

Additional components of the MSE were defined in Policy ID: XII-70 Medical Screening Exam and Triage-Adult and Pediatric, revised 7/10, and included an assessment of the chief complaint, vital signs including pain level, mental status compared to baseline, skin assessment, the ability to walk, a focused physical exam and the description of the patient's general appearance. A pertinent medical and surgical history was to be obtained as well as a list of medications taken by the patient and any allergies.

In addition, Policy ID: XII-70 defined the education and training requirements for nurses assigned to Internal Triage (ambulance entrance) and External Triage (lobby entrance) areas. The requirement for annual certification included a successful review, by an ANII (Assistant Nurse Manager or designee), of a minimum of ten triages performed by the nurse.

In an interview with NM1 and the ED Nurse Educator on 12/15/12 at 11 a.m., they acknowledged none of the nurses currently assigned to triage patients who presented to the ED had had a minimum of ten triages reviewed annually by the ANII or designee.

b. In review of the Medical Staff Rules and Regulations, dated July 2011, there was no evidence of the approval of the medical staff for nurses in Labor and Delivery [the Birthing Suites] to initiate the MSE.

In an interview with the Chief Nurse Executive (CNE) on 1/13/12 at 10 a.m., she acknowledged there was no oversight by the medical staff for nurses initiating the MSE in Labor and Delivery.

In a tour of the Birthing Suites on 2/13/12 at 11:31 a.m., an interview was held with a Registered Nurse (RN1) who stated she had been working in triage for a year and was assigned to triage patients arriving to Labor and Delivery. RN1 stated she would assess the patient and inform the physician of her findings. In a concurrent interview, RN2, who also was assigned to work in the triage area was asked what triage competencies were reviewed and when was this done. The nurse responded "We report to the residents [physicians in training]. They'll tell us if we did something wrong." Both RN1 and RN2 were not aware of any review of competencies for the initiation of the MSE in Labor and Delivery.

In an interview with an Assistant Director of Nursing (ADON) on 2/13/12 at 11:43 a.m., she further acknowledged the medical staff had not determined the nurses in Labor and Delivery were qualified to initiate the MSE.

In review of facility Policy ID: XVI-23 titled Triage of the Perinatal Patient Equal to Or Greater Than 36 weeks Gestation by the Perinatal RN, revised 01/27/2012, there was stipulation that ".... [Labor and Delivery] staff will comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) (Hospital P&P 1101)". The policy directed the nurse to assess the patient and inform the physician of the fetal heart rate evaluation, the patients obstetrical and medical history, chief complaint and vital signs and the results of a vaginal or speculum exam, if indicated. The policy further revealed "The patient may be discharged by the nurse after discussion of the case with a ...resident or faculty. The only competency defined for the Labor and Delivery nurse was the requirement for a minimum of two years of labor and delivery experience required prior to being assigned to triage. There was no annual review of the competencies of the Labor and Delivery nurse.

In review of facility Policy ID: XII 70 titled Medical Screening Exam and Triage-Adult and Pediatric, revised 07/12/2010, Attachment D Triage of the Pregnant Patient, there was stipulation "Patients presenting to Labor and Delivery will have the medical screening evaluation completed in that area". There was no reference to the labor and delivery nurse, the required competencies or his/her role in initiating the MSE.

In review of facility Policy ID: 1101 Emergency Medical Treatment and Labor Act (EMTALA), revised 12/28/2011, Page 2, there was stipulation "A physician, certified nurse midwife, or another qualified medical person acting within his/her scope of practice, ...Medical Staff Bylaws and State law may certify whether or not a woman is in false labor, after a reasonable time of observation".
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to to provide evidence that the physician had:
1. Certified, based on information available at the time of transfer, that the medical benefits outweighed the risks of transfer,
2. Completed a written summary of the reason for transfer and the risks and benefits of transfer, and
3. Informed the patient of the risks and benefits of transfer for 4 of 7 sampled patients (8, 9, 12, 13) who were transferred from the Emergency Department (ED) to an acute psychiatric hospital (APH) between 8/1/11 and 2/13/12.

Findings:

a) Patient 8, a 39 year old, presented to the Emergency Department (ED) on 8/7/11 at 11:07 p.m. Patient 8 presented with complaints of suicidal ideation and drug use, and was assigned triage level orange. Patient 8 was transferred to an APH at 8:17 a.m. on 8/9/11.

b) Patient 9, a 29 year old, (MDS) dated [DATE] at 12:44 p.m. Patient 9 presented with complaints of feeling like hurting himself, and was assigned triage level yellow. Patient 9 was transferred to an APH at 7:59 p.m. on 8/1/11.

c) Patient 12, a 61 year old, (MDS) dated [DATE] at 9:19 p.m. Patient 12 presented with complaints of chest pain and anxiety, and was assigned triage level red. Patient 12 was transferred to an APH at 12:09 p.m. on 10/21/11.

d) Patient 13, a 53 year old, (MDS) dated [DATE] at 2:58 p.m. Patient 13 presented with various psychiatric complaints (history of schizophrenia, claimed he was electrocuted and being poisoned), and was assigned triage level yellow. Patient 13 was transferred to an APH at 11:42 a.m. on 1/17/12.


In a concurrent interview and clinical record review with the Emergency Department Clinical Nurse III (ED-CNIII), he confirmed the following:
i) The clinical records for Patients 8, 9, 12, and 13 did not contain a physician's certification that the medical benefits outweighed the risks of transfer,
ii) There were no transfer summaries that included the reason for transfer and the risks and benefits of transfer,
iii) There was no evidence of discussion with the patients concerning the risks and benefits of transfer.

In an interview with the Chief Of Staff (COS) on 2/15/12 at 8:30 a.m., he stated a Transfer Summary was not done by the physician on patients who were transferred to an APH as the medical staff considered these patients to be discharged , not transferred.

Facility Policy ID: 1101 titled Emergency Medical Treatment and Active Labor Act (EMTALA), revised 12/28/11 stipulated the following:
V. PROCEDURES, 3. "Certification for Transfer . . . transfer may only occur if a physician certifies that the transfer is in the best interests of the patient . . . the physician must sign a certification that . . . the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual . . . from being transferred. The certification must contain a summary of the risks and benefits . . . An express written certification is required . . . cannot be implied from the findings in the patient medical record . . . must state the reason(s) for transfer . . . "