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LITTLETON ADVENTIST HOSPITAL, CENTURA HEALTH 7700 S BROADWAY LITTLETON, CO 80122 Aug. 25, 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 Labor Act (EMTALA) requirements.

FINDINGS:

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

Tag A2405 - emergency room Log

Based on interview and record review, the facility failed to maintain a central log that contained accurate information regarding disposition and transfer of patients that had received treatment in the Emergency Department (ED) for 5 of 18 ED records reviewed (Patients #4, #6, #17, #19 and #20).

Tag A2406 - Medical Screening Exam

Based on interviews and document review, the facility failed to ensure an appropriate Medical Screen Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation was provided by qualified medical personnel (QMP) in 2 of 5 records reviewed for patients who presented to the obstetrical unit for emergency services (Patients #3 and #21).
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to maintain a central log that contained accurate information regarding disposition and transfer of patients who had received treatment in the Emergency Department (ED) for 5 of 18 ED records reviewed (Patients #4, #6, #17, #19 and #20).

Findings:

POLICY

According to the policy, titled Emergency Medical Treatment & Active Labor Act (EMTALA), a central log must list each individual seeking or in need of emergency services that comes to the hospital. The log 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 .

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

a) Review of the EMTALA log, dated 08/21/16, revealed Patient #6 presented to the ED at 2:48 p.m. with a headache and eloped from the ED at 5:35 p.m. on 08/21/16.

However, review of Patient #6's medical record showed the patient's father received discharge instructions at 5:30 p.m. and the patient was discharged home. According the the ED Patient Discharge, dated 08/21/16 at 5:35 p.m., Registered Nurse #21 (RN) documented the patient was discharged home with his/her family. This was in contrast to the EMTALA centralized log which noted the patient eloped.

On 08/24/16 at 10:35 a.m. an interview and record review for Patient #6 was conducted with the ED Nurse Manager (Manager #5). Manager #5 reviewed the record and acknowledged the patient was discharged home on 08/21/16 and did not elope. S/he stated the unit secretary would have looked for the correct disposition for Patient #6 on 08/22/16 and should have corrected it if it was inaccurate.

b) Review of the central (EMTALA) log showed Patient #4 (MDS) dated [DATE] at 4:48 p.m. for pregnancy problems.

There was no documentation on the central log to indicate if the patient was treated, transferred, admitted or discharged . Specifically, the area for documenting the clinical impression, disposition and disposition date and time was left blank.

c) Review of the EMTALA log for 08/16/16 showed Patient #17 presented at 5:46 p.m. for abdominal pain and was diagnosed with appendicitis. However, there was no disposition on the central log.

Review of Patient #17's Emergency Department Report, dated 08/16/16, revealed the patient had appendicitis and was to be admitted to general surgery. The patient underwent a laparoscopic appendectomy and was discharged home on 08/17/16 at 9:15 a.m.

d) Similar findings were noted for Patients #19 and #20 regarding the facility's failure to note the disposition on the central EMTALA log.

e) An interview was conducted with Manager #5 and the Director of Critical Care & ED (Director #6) on 08/24/16 beginning at 10:15 a.m. Director #6 stated the ED unit secretary would print the EMTALA log for the previous day after midnight. Director #6 acknowledged there was not a process for them to go back and revisit the disposition if the patient was in the ED after midnight. Additionally, s/he stated if the patient left the ED for a procedure (GI lab, radiology or the operating room) it would not populate the EMTALA log as the patient would not be discharged from the ED.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on interviews and document review, the facility failed to ensure an appropriate Medical Screen Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation was provided by qualified medical personnel (QMP) in 2 of 5 records reviewed for patients who presented to the obstetrical unit for emergency services (Patients #3 and #21).

This failure created the potential for delays in diagnosis and treatment of emergency medical conditions.

FINDINGS:

POLICY

According to the Medical Staff Bylaws, Policies, and Rules and Regulations, Appendix III, hospital staff that are approved to perform a medical screening examination include OB RN's (Registered Nurses) once additional training and competencies are completed.

According to policy, Obstetrical Medical Screening Exam, the medical staff through the medical executive committee shall determine the criteria for L&D (Labor & Delivery) RN's deemed to be of sufficient experience and competence to perform medical screening examinations. The policy goes on to identify the RN requirements to include-

- Labor and delivery RN's individually certified as competent by the medical staff through the medical executive committee prior to performing any medical screening examinations
- All labor RN's performing medical screen must have a minimum of 1 year OB experience and be certified in electronic fetal heart rate monitoring
- Completion of medical screening and EMTALA education prior to performing independent medical screening for OB patients

1. The facility failed to ensure registered nurses performing medical screening examinations to determine if pregnant women were in active labor, were qualified and authorized to perform such examinations.

a) A tour of the labor deck occurred on 08/23/16 in the a.m. The nurse manager of the labor deck (Manager #1) was asked to identify the required qualifications for nurses performing medical screening examinations on the labor deck to determine if an emergency medical condition existed.

Manager #1 responded "the nurse must have one year of experience working on the labor deck, been certified to perform fetal heart monitoring and have been signed off on by one of the physicians."

b) Medical record review revealed Patient #3 came to the labor deck on 07/12/16. Patient #3 was 32 weeks pregnant with complaints of contractions, bloody show and concerns of labor. One of the labor and delivery nurses (Registered Nurse, RN #2) obtained physician orders to evaluate the patient for labor and perform electronic fetal heart monitoring.

After performing the medical screening examination and fetal heart monitoring, RN #2 consulted the physician and obtained a verbal order to discharge the patient home. There was no indication in the medical record the physician personally examined the patient.

c) The employment file for RN #2 was reviewed. RN #2 was a registered nurse with less than one year obstetrical (OB) experience. S/he had transferred to the labor deck in 2016. The employment file revealed RN #2 had been certified to conduct fetal heart monitoring on 06/22/16. There was no evidence RN #2 had been certified as competent by the medical staff to perform medical screening examinations.

d) On 08/24/16, Manager #1 reviewed the medical record for Patient #3 with the surveyor. Manager #1 agreed there was no evidence in the medical record that Patient #3 had been examined by a physician or other QMP on 07/12/16. S/he confirmed RN #2 had worked on the labor deck for less than one year and had not been validated to perform obstetrical medical screening examinations.

e) The employment file for RN #3 was reviewed on 08/24/16. The Obstetrical Medical Screening Examination RN Competency Validation form had been completed by RN #3 and a member of the medical staff on 08/24/16.

RN #3 was interviewed and indicated s/he had been hired on the OB unit in July of 2015. S/he had previous OB experience that was documented in the employment file. When asked how long s/he had been performing medical screening examinations at this facility, RN #3 replied, "since about January 2016." When asked if s/he had been evaluated by a member of the medical staff to perform medical screening examinations prior to 08/24/16, s/he replied "I think so."

However, there was no documentation to show RN #3 had been evaluated by a member of the medical staff and deemed competent to conduct a MSE prior to 08/24/16.

f) Medical record review revealed Patient #21 came to the labor deck on 08/15/16 for evaluation following a minor motor vehicle accident. RN #3 performed the medical screening examination and fetal heart monitoring and received verbal orders from a physician that the patient could be discharged based on results from the monitoring. There was no documentation in the medical record that the physician personally examined the patient or that Patient #21 was evaluated by a QMP.