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CENTURA HEALTH-ST ANTHONY HOSPITAL 11600 WEST 2ND PLACE LAKEWOOD, CO 80228 April 22, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on observations, interviews and document records, the facility failed to comply with the Medicare provider agreement as defined in 489.20 and 489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

Findings:

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

Tag A 2405 - emergency room Log
Based on interview and record review, the facility failed to maintain emergency room Log that contained accurate information about disposition and transfer of patients that had received treatment in the Emergency Department (ED) for 7 of 20 records reviewed (patients #4, #6, #7, #8, #10, #12 and #15).
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on interview and record review, the facility failed to maintain an emergency room Log that contained accurate information about disposition and transfer of patients that had received treatment in the Emergency Department (ED) for 7 of 20 records reviewed (patients #4, #6, #7, #8, #10, #12 and #15).

Findings:

POLICY

According to the policy titled Emergency Medical Treatment and Active Labor Act - EMTALA, the hospital will maintain a log of all individuals seeking or in need of emergency services who come to the hospital. The log will include information about whether each individual did not consent to treatment or transfer, or was transferred, admitted and treated, stabilized and transferred, or discharged .

1. The facility failed to maintain a complete and accurate log of patients who presented to the Emergency Department (ED), including an accurate record of the patients that were transferred or discharged .

a) At 10:50 a.m. on 04/21/15, an interview was conducted with Employee #2, who provided written transfer logs for the ED and the Psychiatric ED. S/he stated the logs were a part of the ED log and contained more detailed information about each patient that was transferred out of the ED. S/he stated the transfer logs contained information about which specific hospital a patient was transferred to after leaving the ED.

Employee #2 stated the required ED log was a combination of the electronic log initially provided, as well as the 2 handwritten transfer logs for the ED and Psychiatric ED.

b) Subsequent review, on 04/21/15, of the handwritten transfer logs for the ED and Psychiatric ED revealed that for Patients #6, #7 and #8, listed on the Psychiatric ED transfer log, and for Patient #15, listed on the ED transfer log, none of the patients were actually transferred.

A notation on the entry for each patient noted that the transfers had not actually occurred, either because it had been canceled or the patient was evaluated and referred for outpatient services and sent home. All 4 sample patients (#6, #7, #8 and #15) had all been discharged to home, even though they had been entered on the transfer logs.

c) On 04/21/15 at 11:55 a.m., Employee #2 was interviewed again when s/he came in to provide total transfer number to complete the transfer section (#2) of the EMTALA form HCFA-1541B during the survey. S/he was notified by surveyors that the review of the ED and Psychiatric ED transfer logs had indicated at least 4 instances (patients #6, #7, #8 and #15) in which the patients that appeared on the transfer log had not actually been transferred, but instead discharged .

Employee #2 was asked if the numbers for transfers had been calculated by counting the number of entries on the the ED and Psychiatric ED logs. Employee #2 stated s/he had counted the entries to arrive at the number and believed the patients that were not actually transferred, but incorrectly identified on the transfer logs, had been included in the total transfer numbers. Employee #2 reviewed the logs again and determined an actual number of transfers for the report (form HCFA-1541B). S/he provided a final count of the transfers at 1:24 p.m.

d) Review of the electronic ED log, 04/21/15, revealed Patient #4 was listed with a disposition code "AIP," which the key described as admitted to the facility as an inpatient.

However, review of the ED transfer log for Patient #4 showed the patient had been discharged to another acute inpatient hospital. Review of the 04/06/15 medical record for Patient #4 revealed the patient had been transferred to another acute care inpatient hospital, rather than admitted to the facility as indicated on the electronic part of the ED log.

e) Review of the electronic ED log revealed Patient #10 was listed as a transfer to an acute inpatient hospital.

In contrast, review of the ED transfer log revealed the patient was not listed on the log as a transfer. Review of the ED medical record for Patient #10 revealed the patient had been discharged back to the skilled nursing facility where the patient had been receiving care prior to the ED visit on 02/02/15.

f) Review of the electronic ED log and disposition code key, on 04/21/15, revealed Patient #12 was listed as "ELP," which the key indicated as an elopement from ED. The diagnosis column of the electronic log stated the "patient left without being seen." Review of the 02/02/15 ED medical record for Patient #12 revealed the patient had been seen by the provider but had eloped prior to all diagnostic test being completed.

g) On 04/22/15 at 10:30 a.m., an interview was conducted with Employee #4 to review and confirm the findings related to disposition of Patients #4, #10 and #12.

S/he reviewed the ED medical record for Patient #4 and confirmed the patient had actually not been transferred, but discharged back to the skilled nursing facility where the patient had been residing prior to ED visit. S/he reviewed the ED log and confirmed the wrong code had been entered for disposition, indicating that the patient had been transferred to another acute care hospital, when that was not the true disposition.

Employee #4 reviewed the ED medical records and confirmed Patient #10 had been discharged to a skilled nursing facility and that the disposition code on the ED log did not reflect what had actually occurred with the patient.

Additionally, Employee #2 confirmed Patient #12 had been seen by the provider, received an assessment and was not actually a patient that had left without being seen. When asked if there was a code for "left without being seen," s/he provide a copy of the key in the electronic medical record for dispositions and identified a code that stated "patient left without being seen." S/he stated that sometimes that code was not consistently used.

h) On 04/21/15 at 4:00 p.m., Employee #1 was interviewed about the inaccuracies in the ED and Psychiatric ED transfer logs and confirmed that there were patients listed as Psychiatric ED transfers (Patients #6, #7 and #8) and a patient on the ED transfer log (Patient #15) that were not actually transferred. The manager was unable to explain the inaccuracy related to the ED transfer log (Patient #15), but attributed the inaccuracies in the Psychiatric ED transfer log as possibly related to new psychiatric evaluators that might have been using the log to record their referrals for evaluation, rather that maintaining it as an accurate list of transfers. S/he stated they had some new staff that may not have been clear on the intent of the log. Employee #1 stated the staff would be re-trained to ensure more accuracy for the ED and Psychiatric ED transfer logs.