The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

LUTHERAN MEDICAL CENTER 8300 W 38TH AVE WHEAT RIDGE, CO 80033 March 24, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interviews and document review, the facility failed to comply with the Medicare provider agreement, as defined in 489.24, related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

FINDINGS:

1. The facility failed to meet the following requirements under the EMTALA regulation:

Tag A2409 - Restricting Transfer Until the Individual Is Stabilized

Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in 489.24 related to the Emergency Medical Treatment and Active Labor Act (EMTALA) requirements. Specifically, the facility failed to ensure that consents for transfer were completed for 2 of 5 patients (Patients #8 and #14) who were transferred to another facility for higher level of care or specialty services.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in 489.24 related to the Emergency Medical Treatment and Active Labor Act (EMTALA) requirements. Specifically, the facility failed to ensure that consents for transfer were completed for 2 of 5 patients (Patients #8 and #14) who were transferred to another facility for higher level of care or specialty services.

This failure created the potential for patients to transfer without full disclosure of their rights and risks of transfer.

FINDINGS:
POLICY

According to policy, Emergency Medical Treatment and Labor Act (EMTALA), the hospital shall document its communication with the receiving hospital in the medical record, including the date and time of the communication and the name of the person accepting the transfer. The hospital shall inform the individual of its obligations to provide an Emergency Medical Examination and stabilizing treatment. The treating physician or Qualified Medical Personnel (QMP) shall explain the risks and benefits associated with the transfer to the individual. If the transfer is requested by the individual, the request shall be made in writing on the Patient Transfer Form, indicating the reason (s) for the request, that the individual has been informed of the Hospital's obligations to provide a Medical Screening Exam (MSE) and stabilizing treatment, and that the individual has been informed of the risks and benefits of transfer. The signed Patient Transfer form shall be placed with the medical record. The individual must agree to the transfer. If the transfer is not at the request of the individual, the hospital shall document that the individual has agreed to the transfer by having the individual sign the Patient Transfer form.

1. The facility failed to complete EMTALA Patient Transfer Forms for patients who were transferred to another facility for higher level of care or specialty services.

a) Review of Patient #14's medical record revealed on 02/06/16, the patient presented to the Emergency Department secondary to a fall, with complaints of left hip pain and nausea. Patient #14 was transferred to another medical facility after receiving a completed medical screening examination, for continued orthopedic care needed for a surgical repair of the patient's left hip fracture. Patient #14's medical record lacked evidence of a Patient Transfer Form which showed physician certification, stabilization of the patient, reason for transfer, benefits and risks of transfer, and transfer method.

Additionally, there was no evidence to show the patient was aware of the risks and benefits of transfer, his/her request or acceptance of transfer, and acknowledgement of the facility's obligations for treatment.

b) Review of Patient #8's medical record revealed on 03/19/16, the patient presented to the Emergency Department (ED) with complaints of shortness of breath. Patient #8 had a chest tube placed for a right side pneumothorax (the presence of air or gas in the cavity between the lungs and the chest wall, causing collapse of the lung). According to the Discharge Summary dated 03/20/16, Patient #8's oxygen requirements improved overnight with oxygen requirements decreased from 15 liters/per minute to 3 liters/per minute. Although, the Discharge Summary note stated the patient and his/her spouse requested to be transferred to another facility where the patient was known to the oncology service; there was no documentation on the Patient Transfer Form to show the patient consented to the transfer and the documented risks, benefits, and facility obligations were explained to the patient's satisfaction.

c) On 03/24/16 at 1:20 p.m., an interview was conducted with Physician #1 who stated the Patient Transfer form should be completed with any transfer. Physician #1 stated the patient must sign the transfer form, and if unable to sign, the nurse should document the patient was unable to consent.

After review of Patient #8's incomplete transfer form, Physician #1 stated the consent should be filled out, and if the patient was unable to sign, the nurse should have signed as the witness.

After review of Patient #14's missing transfer form, Physician #1 stated "that's a problem" if there was no form and the expectation was a form would be filled out with every transfer. Physician #1 stated the left side of the form which indicated the patient's status, risk and benefits of the transfer, and physician certification, was the physician's responsibility. Physician #1 stated the right side of the form which included the patient's signature for consent for transfer, request for transfer, and acknowledgement of the risks and benefits of the transfer, was the nurse's responsibility for completion.

d) On 03/24/2016 at 4:31 p.m., an interview was conducted with Registered Nurse (RN) #2 who was the ED's Clinical Coordinator. RN #2 stated both the nurse and physician were responsible for completing the patient transfer form and consent. RN #2 stated there was no process to ensure forms were completed for every transfer. After review of Patient #8's medical record, s/he stated the expectation was for the form to be filled out completely.