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UNIVERSITY OF COLORADO HOSPITAL AUTHORITY 12605 EAST 16TH AVENUE AURORA, CO 80045 Sept. 11, 2015
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


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 transfers sent from its Emergency Department, by private vehicle, to an outside facility for a higher level of care, were appropriately carried out in 7 out 7 (Patients #5, #16, #17, #18, #19, #20, and #22) pediatric transfers reviewed.

The failure created the potential that patients transferred in this manner would not receive necessary medical treatment.

FINDINGS:

POLICY

According to the facility document, Medical Screening Examinations, Stabilizing Treatment and Appropriate Transfer (EMTALA), prior to transfer from the facility the hospital must provide sufficient medical treatment within its capability to minimize risks to the individual's health. The transferring physician must select and document an appropriate transportation arrangement including mode of travel, time and distance, equipment availability, and the qualifications of transport personnel.

1. The facility failed to ensure that transfers of pediatric patients, by private vehicle, were carried out as intended by Emergency Department (ED) physicians. The facility did not have a process in place to ensure that these pediatric patients arrived at the receiving facility, in order to receive further medical care and a higher level of care.

a) Review of the medical record revealed Patient #20, a 2 month old, was admitted on [DATE] at 8:14 p.m., for fever, diarrhea, and vomiting. Review of the Assessment/Plan revealed Patient #20 had symptoms of a temperature of 38.0 degrees Celsius for 3 days, along with multiple episodes of diarrhea, spitting up, and persistent crying. The treating physician determined a possible diagnosis of sepsis (systemic infection). The medical record revealed the patient was transported by privately owned vehicle (POV) in the care of his/her parent, who had moved to the area 2 weeks prior to the ED visit.

Documentation showed the parent was given Discharge Instructions which stated "Please go directly to the emergency department at [the receiving hospital] for continuation of care." The record showed the patient departed the ED at 10:14 p.m., 2 hours after admission, in route to the receiving facility.

At 3:00 a.m. the next morning, 05/13/15, an entry in the medical record, made by a registered nurse, revealed Patient #20 had not arrived as expected to the receiving facility. The medical record revealed the nurse called the patient's contact number but did not contact or speak with the parent. The medical record did not reveal that this lack of arrival at the receiving facility was shared with others in the ED.

b) On 09/10/15 at 1:00 p.m., an interview was conducted with the treating physician (MD #1). MD #1 revealed s/he was not aware Patient #20 had not arrived at the outside facility ED as planned and documented in the patient's medical record. MD #1 stated that the parent of the child may have "decided the child was OK" and that s/he assumes that a parent "cares enough and is responsible since they brought the child to the ED in the first place" to drive to the receiving facility.

c) The Medical Director (MD #3) of the ED was interviewed on 09/10/15 at 4:38 p.m. MD #3 was not aware Patient #20 had not arrived at the receiving facility as planned. MD #3 stated the facility did not have a process in place to ensure patients who were transferred from the ED by privately owned vehicle (POV) arrived at the receiving facility as intended by the ED physicians. MD #3 further stated the transfer consent form signed by the patient, in this case the parent, placed liability for the transfer on the parent. MD #3 stated the facility did not make phone calls to the receiving facility to inquire about the arrival of pediatric patients transferred by private vehicle. MD #3 stated there was no process in place to ensure these private vehicles arrived or did not arrive at the receiving facility and further stated this was not the facility's responsibility. MD #3 stated cases such as the transfer of Patient #20 by private vehicle were considered transfers and EMTALA paperwork was completed and given to the parents to take to the receiving facility.

d) Review of the medical record revealed Patient #22, a 9 month old, was admitted on [DATE] at 8:08 p.m., with a fever for 2 days. Medical record review revealed the treating physician had not arrived at a diagnosis. Within the medical record was a Physician Certification Statement of Medical Necessity for Ambulance Transportation to another facility.

Further review of the record showed Patient #22 was transported at 9:20 p.m. by POV.

No documentation within the record revealed that the parent of Patient #22 had refused to be transported by ambulance or that any discussion had taken place surrounding the change of mode of transportation. Further, there was no documentation to show that Patient #22 arrived as planned at the receiving facility.

e) The emergency department (ED) Medical Director (MD #3) was interviewed on 09/10/15 at 4:38 p.m., and reviewed the medical record of Patient #22. MD #3 stated "I have to agree that the documentation does not indicate what the doctor was thinking as to why this child was transferred." MD #3 stated that if an otherwise healthy infant exhibited a fever without any clear reason, there was a need for further medical workup, such as a lumbar puncture.

In an interview with MD #3 on 09/09/15 at 1:00 p.m., s/he stated "I do expect the doctor to document everything that was done prior to a transfer."

f) Review of the medical record revealed Patient #5, a 3 year old, arrived at the ED on 08/13/15 at 8:55 p.m. to be treated for a laceration (cut) to his/her forehead, which had been sustained during a trip and fall on a concrete step.

According to the Emergency Medical Treatment and Active Labor Act (EMTALA) transfer form in the medical record, the reason for transfer was a closed head injury which required treatment by qualified clinical personnel unavailable at the ED.

g) During an interview on 09/10/15 at 4:38 p.m., MD #3 reviewed the record of Patient #5 and stated the conversation with the parent was usually that the facility wants the child to be transported by ambulance but the parent will choose to transport the child by private vehicle. S/he also stated "it appears to me this is an agreement between the parent and the doctor."

Review of the medical record revealed no documentation to show that any discussion with the parent of Patient #5 had taken place about the mode of transport or that the parent refused ambulance transport to the outside facility ED. No documentation was present in the medical record to show that Patient #5 had arrived at the receiving facility as planned.

h) Review of the medical record revealed Patient #18, a 4 year old, was admitted on [DATE] at 9:07 p.m., after experiencing 6 episodes of vomiting and 2 diarrhea stools. The treating physician documented in the Assessment/Plan section that the patient was listless and had a developmental disorder.

Further review of the Emergency Medical Treatment and Labor Act (EMTALA) Transfer Form revealed the physician decided that Patient #18 required pediatric evaluation and necessities available at an outside facility.

There was no documentation that showed the parent of Patient #18 was advised to transport the child by ambulance or that the parent had refused such advice.

i) An interview with the treating physician, MD #2, was conducted on 09/10/15 at 3:16 p.m. MD #2 stated that s/he always had the conversation with families about the use of an ambulance to transport a patient to another facility and that s/he always discussed the risks of transport by car. MD #2 stated the documentation in the record of Patient #18 did not reflect the conversation, but s/he had developed a practice over the years to ensure the families understood all the risks of travel by private vehicle.

MD #2 further stated there was no process to verify that a patient traveling by private vehicle arrived at the receiving facility and there "is likely a need to close the loop when transferring a patient out" by private vehicle.

No documentation in the medical record revealed Patient #18 had arrived at the receiving facility as planned.

j) Review of the medical record revealed Patient #16, a 13 year old, arrived at the ED on 05/31/15, at 2:17 a.m. It was documented the patient had swollen lymph nodes to the right side of his/her neck and a dental infection. According to the Assessment/Plan, the treating physician's diagnosis was infection of the jaw, ear, and glands of the neck which would require admission for intravenous antibiotics. The plan of the treating physician was to transfer Patient #16 to an outside facility for continued treatment. According to the Emergency Medical Treatment and Labor Act (EMTALA) Transfer form, the Level of Care needed for transfer was private vehicle.

Patient #16 departed the facility ED at 4:24 a.m. There was no documentation of discussion with the family to show they had refused an ambulance transport or that it had been offered. Additionally, there is no documentation in the medical record to show that Patient #16 arrived at the outside facility for the care s/he required.

k) Review of the medical record revealed Patient #17, a 13 year old, was admitted to the (ED) at 7:19 p.m., on 09/02/15 with open forearm wounds and depressive disorder. According to the treating physician's Assessment/Plan, Patient #17 had self mutilated and was suspected of having made a suicide attempt. The plan for Patient #17 was to transfer him/her to an outside hospital for psychiatric evaluation by a pediatric specialist.

Further review of the Assessment/Plan revealed the parents of Patient #17 had "elected to go by private vehicle." however, no documentation was present to show Patient #17 arrived at the outside facility for the care s/he required.

l) Review of the medical record revealed Patient #19, a 14 year old, arrived at the ED on 09/03/15 at 10:56 p.m., with pain to the right upper abdomen. Patient #19 had a history of similar pain due to gallstones. According to the Assessment/Plan and the Emergency Medical Treatment and Labor Act (EMTALA) form completed by the treating physician, Patient #19 required pediatric "qualified clinical personnel unavailable" at the admitting ED.

Additionally, the Assessment/Plan read the "father is here and willing to transport the patient" by private vehicle. There was no documentation to show the father was given the opportunity to accept or decline ambulance transport.

At 12:29 a.m. Patient #19 was sent by private vehicle to an outside facility ED to receive additional care. There was no documentation in the medical record to show that Patient #19 arrived at the outside facility ED.