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.

AUBURN COMMUNITY HOSPITAL 17 LANSING STREET AUBURN, NY 13021 April 25, 2017
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on findings from document review and interview, in 1 of 20 medical records (MR) reviewed the hospital failed to ensure that a patient (Patient #1) had a medical screening exam (MSE) prior to transportation to another hospital for a higher level of care. This lack of a MSE could place patients at risk for untimely treatment of an emergency medical condition.

Findings include:

-- Review of the emergency medical services (EMS) record for Patient #1 revealed, on 4/14/17 at 2:09 am, EMS was called to Auburn Community Hospital (ACH) due to a patient jumping from the second level of the hospital parking garage. EMS arrived on the scene at 2:12 am and indicated a [AGE] year old female patient was lying supine on the driveway of ACH parking garage. She was alert and oriented to person , place and time. Patient #1 was immobilized with a cervical collar and was in the care of ACH staff and Auburn Fire Department. She was complaining of right chest wall pain, left wrist pain, left hip pain, jaw pain and pain when taking deep breaths. She had a laceration on her chin. Patient #1 denied any head, neck or back pain. The Advanced Emergency Medical Technician completed an assessment of Patient #1 and immobilized her on a backboard. The patient was then loaded into the ambulance and transported to the nearest trauma center (30 miles away).

-- Per interview of Staff C (Registration Clerk) on 4/24/17 at 3:00 pm, Patient #1 and her father presented to the Emergency Department (ED) on 4/14/17. While Patient #1's father initiated the ED log in process, Patient #1 ran out of the ED waiting room. Staff C and others ran out after Patient #1 and discovered that she had fallen from the 2nd floor of the parking garage. Staff C ran back into the ED and alerted Staff A (ED Clinical Leader) that they needed help. Staff A instructed Staff C to call 911.

-- Per interview of Staff A on 4/25/17 at 9:00 am, he/she was the Clinical Leader on the night shift. He/she was alerted by Staff that Patient #1 had gone over the edge of the 2nd floor of the parking garage. He/she instructed Staff to call 911. Staff A ran outside and found Patient #1 on the ground with a security guard and her father at her side. Staff A instructed security staff to make sure 911 was called. Staff A performed a neurological exam and found Patient #1 to be alert and oriented, able to move all extremities. Patient #1 had pelvic tenderness and a laceration to the chin. Staff A completed C-spine immobilization with application of a cervical collar. EMS arrived and placed Patient #1 on a backboard. The ambulance crew stated they were bypassing the hospital's ED and transporting the patient to a trauma center. Staff A stated that she did not document his/her assessment, notify the ED physician or call a "Code Blue" but followed the New York State Trauma Protocol in the treatment of Patient #1.

-- Per interview of Staff F (ED Physician) on 4/25/17 at 8:30 am, he/she was the attending physician in the ED. He/she was not aware of Patient #1 going over the top of the parking garage at the time it happened. However, during interview of Staff I (ED Registered Nurse) on 4/25/17 at 10:00 am, He/she notified Staff F that Patient #1 had fallen off the roof of the parking garage.

-- Per interview of Staff B (Nursing Supervisor) on 4/25/17 at 11:00 am, he/she responded to a page from the operator stating that he/she needed to go to the ED, no details were provided. Upon arrival to the scene, EMS had Patient #1 on their stretcher. Staff B then returned to the ED to prepare a room, assuming that EMS personnel were going to bring Patient #1 in. After several minutes, when Patient #1 didn't present to the ED he/she learned that EMS staff had transported Patient #1 to a trauma center.

-- Per interview of Staff D (ED Medical Director) on 4/25/17 at 12:35 pm, he/she stated that the ED staff responded appropriately to Patient #1's injuries. Staff D stated that the EMS provider manual clearly indicates that the most highly trained individual on the scene makes the decision to transfer. ED physicians typically don't go outside to respond to emergencies, generally, patients are brought back into the ED. Staff D further stated that paramedics have the authority to make the decision to transfer a patient and that in this situation it was appropriate for them to do so; he/she did not expect the ED physician to be involved.

Patient #1 was not provided a MSE even though she was on hospital grounds and was in need of emergency care.
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on findings from document review and interview, the hospital failed to implement an effective Emergency Medical Treatment and Labor Act (EMTALA) training program for hospital staff and providers. The training program lacked information related to e.g., appropriate transfer of patients, hospital responsibility for patients on hospital grounds but not in the Emergency Department (ED), central log requirements, etc.) Staff did not respond to an emergency situation on hospital grounds per EMTALA requirements and facility policies and procedures (P&P). Medical Staff were not educated annually about EMTALA. These lapses could lead to untoward patient outcomes.

Findings include:

The hospital's 2017 EMTALA training program mandated for hospital staff (not required for providers) contained only the following information:
-- When a patient comes to the ED, the hospital must screen for a medical emergency.
-- If an emergency medical condition is found, the hospital must provide stabilizing treatment.
-- Patients with emergency medical conditions may not be transferred out of the hospital for economic reasons.

-- Review of the hospital's P&P titled "Emergency Cart Call - Code Blue, Code White, Code Purple," last revised 11/28/16, directed ED nurses to respond to a cardiac and respiratory arrest with full code response housewide for code blue calls on hospital property including outside buildings. In these instances the code will be directed by ED staff/physicians. ED emergency cart responds to outside building areas.

-- Review of the hospital's P&P titled " EMTALA Medical Screening Examination (MSE)," last revised 1/5/2015, indicated that if an individual is on Auburn Community Hospital (ACH) campus but is not technically in the ED and is in need of emergency care, he/she must receive a MSE within the capabilities of ACH.

-- Review of the emergency medical services (EMS) record for Patient #1 revealed, on 4/14/17 at 2:09 am, EMS was called to ACH due to a patient jumping from the second level of the hospital parking garage. EMS arrived on the scene at 2:12 am and found a [AGE] year old female patient lying supine on the driveway of ACH parking garage. She was alert and oriented to person, place and time. Patient #1 was immobilized with a cervical collar and was in the care of ACH staff and Auburn Fire Department. She was complaining of right chest wall pain, left wrist pain, left hip pain, jaw pain and pain when taking deep breaths. She had a laceration on her chin. Patient #1 denied any head, neck or back pain. The Advanced Emergency Medical Technician completed an assessment of Patient #1 and immobilized her on a backboard. The patient was then loaded into the ambulance and transported to the nearest trauma center (30 miles away).

Patient #1 was not taken into ACH ED for MSE as required by EMTALA. (See additional findings in Tag 2406)

-- Per interview of Staff A (ED Clinical Leader) on 4/25/17 at 9:00 am, when informed that Patient #1 had gone over the edge of the 2nd floor of the parking garage, he/she instructed a staff person to call 911. He/she did not initiate a code blue as is required by hospital P&P.

-- Per interview of Staff B (Nursing Supervisor) on 4/25/17 at 11:00 am, the ED physician was in the ED at the time, however, he/she was not able to leave the patients in the ED unattended and therefore unable to respond to emergencies outside of the hospital. He/she did not follow hospital P&P that indicates ED staff nurses to respond to code blue calls on hospital property including outside buildings. In these instances the code will be directed by ED staff/physicians.

-- Per interview of Staff C (Registration Clerk) on 4/24/17 at 3:00 pm, Patient #1 presented to the ED but her name was not recorded in ED central log.

-- Per interview of Staff D (ED Medical Director) on 4/25/17 at 12:35 pm, the ED staff responded appropriately to Patient #1's injuries. Staff D stated that the EMS provider manual clearly indicates that the most highly trained individual on the scene makes the decision to transfer. ED physicians typically don't go outside to respond to emergencies, generally, patients are brought back into the ED. Staff D further stated that paramedics have the authority to make the decision to transfer a patient and that in this situation it was appropriate for them to do so; he/she did not expect the ED physician to be involved. However, EMTALA regulations and hospital P&P however required the patient to be provided a MSE.

-- During interview of Staff E (ED Nurse Manager) on 4/25/17 at 1:00 pm, he/she acknowledged that a code blue should have been called for this situation, not 911.

-- Review of Staff D's and Staff F's (ED Physician) credentials files revealed a signed attestation form dated 11/17/14 indicating both providers had reviewed the facility's EMTALA training. However, there is no documentation of EMTALA training since that time.

-- During interview of Staff D on 4/25/17 at 12:35 pm, he/she indicated the ED providers are not required to complete the facility's EMTALA training. He/she stated if there were any changes to the EMTALA policy or laws the facility would inform the providers.

-- During interview of Staff G (Director of Quality Management) on 4/25/17 at 1:00 pm, he/she confirmed the above findings.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on findings from document review, medical record (MR) review and interview, in 4 of 5 medical records reviewed of patients who were transferred to a higher level of care, each lacked documentation of the risks of transfer specific to the patient's medical condition. This could lead to patients not being informed of potential risks related the transfer.

Findings include:

-- Review of the hospital's policy and procedure (P&P) titled "EMTALA (Emergency Medical Treatment and Labor Act) Medical Screening Exam," dated 1/2015, indicated the transfer certification shall include the reason(s) for transfer and summary of the risks and benefits upon which the determination is based.

-- Review of Patient #2's MR revealed, on 4/23/17 Patient #2 was being transferred to a higher level of care for a cardiac catherization. The transfer form titled "Acute Care Transfer - Certificate of Transfer," in the section pertaining to risks contained the following preprinted statement:

All transfers have the inherent risks of traffic delays, accidents during transport, inclement weather, rough terrain, turbulence and the limitations of equipment and personnel present in the vehicle. The RISKS also include: (left blank)

There was no documentation regarding the specific risks of transfer related to the patient's condition.

-- Review of Patient #3's MR revealed, on 3/4/17 Patient #3 was being to transferred due to needing dialysis. The transfer form titled "Acute Care Transfer - Certificate of Transfer," in the section pertaining to risks associated with transfer contained the following preprinted statement:

All transfers have the inherent risks of traffic delays, accidents during transport, inclement weather, rough terrain, turbulence and the limitations of equipment and personnel present in the vehicle. The RISKS also include:

The provider documented a risk of MVA (motor vehicle accident). There was no documentation regarding the specific risks of transfer related to the patient's condition.

-- The same lack of documentation regarding the specific risks of transfer related to a patient's condition were found in Patient #4's and Patient #5's MR.

-- During interview of Staff E (ED Nurse Manager) on 4/25/17 at 1:30 pm, he/she acknowledged the above findings.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on findings from document review and interview, the hospital did not ensure all individuals presenting to the Emergency Department (ED) for evaluation were entered into a central log.

Findings include:

-- Review of the facility's policy and procedure (P&P) titled "EMTALA Central Log," dated 1/2015, indicated a log entry should be made at the first point of contact and be finalized after the medical screening. At a minimum the name of the patient and disposition (e.g., left without being seen, refused treatment, was transferred, etc.) should be documented.

-- Per interview of Staff C (Registration Clerk) on 4/24/17 at 3:00 pm, Patient #1 and her father (MDS) dated [DATE]. While Patient #1's father initiated the ED log in process (documenting name and chief complaint on form), Patient #1 ran out of the ED waiting room. Staff C and others ran out after Patient #1 and discovered that she had fallen from the 2nd floor of the parking garage.

-- However, review of the Central Log dated 4/14/17 revealed, it did not contain any identifying information regarding Patient #1.

-- During interview of Staff H (Vice President for Quality Management) on 4/24/17 at 1:30 pm, he/she acknowledged the above findings.