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.

SOLDIERS AND SAILORS MEMORIAL HOSPITAL 32-36 CENTRAL AVENUE WELLSBORO, PA April 30, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of facility documents, credential files (CF) and staff interview (EMP), it was determined the facility failed to develop a policy to ensure compliance with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA) and the facility failed to ensure practitioners were provided with training related to the requirements of the EMTALA for five of seven CFs reviewed (CF2, CF3, CF5, CF6 and CF7).

Findings include:

1) Request for the facility EMTALA policy was made on April 29 and 30, 2015. No policy was provided.

Interview with EMP1 at 10:00 AM on April 30, 2015, confirmed the facility did not have an EMTALA policy.

2) Review on April 30, 2015, of CF2 revealed this practitioner was privileged to work in the Emergency Department. Further review of CF2 revealed no documentation that CF2 received EMTALA training.

Review on April 30, 2015, of CF3 revealed this practitioner was privileged to work in the Emergency Department. Further review of CF3 revealed no documentation that CF3 received EMTALA training.

Review on April 30, 2015, of CF5 revealed this practitioner was privileged to work in the Emergency Department. Further review of CF5 revealed no documentation that CF5 received EMTALA training.

Review on April 30, 2015, of CF6 revealed this practitioner was privileged to work in the Emergency Department. Further review of CF6 revealed no documentation that CF6 received EMTALA training.

Review on April 30, 2015, of CF7 revealed this practitioner was privileged to work in the Emergency Department. Further review of CF7 revealed no documentation that CF7 received EMTALA training.

Interview of EMP1 at approximately 10:00 AM on April 30, 2015, confirmed these physicians did not have documentation of EMTALA training in their credential files.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure the accepting person's full name and title were obtained before transferring a patient to a receiving facility for one of 18 applicable medical records reviewed (MR1), failed to ensure the accuracy of a patient's consent for transfer for one of 18 applicable medical records reviewed (MR1) and failed to obtain a physician's order for transfer for nine of 18 medical records reviewed (MR1, MR6, MR9, MR10, MR11, MR12, MR14, MR15 and MR18).

Findings include:

Review of the facility's "Transfer of Patient to Another Facility" policy, last reviewed march 2015, revealed "Policy: To provide continuity of care to the patient who requires transfer to another facility. Also to provide patient care in accordance with the Consolidated Omnibus Budget Reconciliation Act of 1985, and 55 PA Code CH.1181 COBRA Transfers and Discharges. In no way will Soldiers and Sailors Memorial Hospital arbitrarily transfer or discharge an individual on the basis of sex, race, creed, color, condition or ability to pay. Purpose: To establish a policy for patients who require transfer to another facility. To ensure that patients who present to SSMH [Soldiers and Sailors Memorial Hospital] for treatment are offered medical stabilization within the capabilities of the hospital prior to being transferred or discharged to another institution. To provide a systematic procedure for coordinating the transport and notification of the transporting service. To effectively and efficiently provide the appropriate level of transportation to the hospital patient that is being transferred/discharged to an outside facility while maintaining continuing of care for that patient. The patient will arrive at the designated transfer facility safely as a result of utilizing this professional standard of practice. ... Procedure: 1. The patient's physician will determine the need for the patient to be transported from the hospital to an outside receiving facility. This order will be written on the patient's medical record. The physician must provide the following information to the staff: a. means of transportation - air or ground b. staffing requirements - paramedics, nurse, EMT [emergency medical technician] c. information to accompany patient - which must be at the nurses' station ready for the transporting personnel to pickup [sic] at the time of patient's transport ... 3. The receiving admission office will be notified along with the receiving nursing unit with a verbal report. Document the name of the person receiving the report. ... 6. When it is time to transfer the patient: ... d. Verify completion of the Physician's Medical Necessity Certification form and the Consent to Transfer form. E. Verify copies of the paper work to be sent with the patient have been made. SSMH will send the receiving medical facility copies of all medical records related to the individual's condition, which are available at the time of transfer. Records should include copies of X-rays, lab reports and ECGs [electrocardiogram]. If available History and Physical, progress notes and any other pertinent medical record such as Medication Records, Medication Reconciliation Sheet and Nurses' Notes should be copied and sent as well. A copy of the complete transfer consent will accompany the patient. Any records not immediately available shall be faxed as soon as possible to the receiving hospital. ..."

The policy did not include the requirement for ensuring documentation of the accepting person's full name and title before transferring a patient to a receiving facility.

1) Review of MR1 on April 29, 2015, revealed this patient presented to the facility's Emergency Department (ED) on April 25, 2015, requesting treatment for substance abuse. The facility contacted another facility to assist in this patient's detoxification for substance abuse. Continued review of MR1 revealed no documentation the facility obtained the accepting person's full name and title before transferring MR1.

Interview with EMP1 and EMP2 on April 29, 2015, at approximately 2:00 PM confirmed the facility's "Transfer of Patient to Another Facility" policy did not include the requirement for ensuring documentation of the accepting person's full name and title before transferring a patient to a receiving facility. EMP1 and EMP2 confirmed MR1 presented to the ED requesting treatment for substance abuse; the facility contacted another facility to assist in this patient's detoxification for substance abuse; and there was no documentation the facility obtained the name and title of the person at the accepting facility.

2) Review on April 29, 2015, of the facility's "Patient's Request / Refusal / Consent to Transfer" form, no review date, revealed "... Transfer Consent I have been informed of my rights regarding examination, treatment and transfer. I acknowledge that my medical condition has been evaluated and explained to me by the emergency department physician or other qualified medical person and / or my attending physician who has recommended that I be transferred to the service of Dr. [name of physician] at [name of facility]. ..."

Review of MR1 on April 29, 2015, revealed the facility completed the Patient's Request / Refusal / Consent to Transfer form for this patient's transfer to another facility. Further review revealed the facility entered a receiving physician's name and the name of the receiving facility on this form.

Interview with EMP1 and EMP2 on April 29, 2015, at approximately 2:45 PM revealed the physician (to provide care at the receiving facility) entered on the Transfer Consent was not on duty at the receiving facility on the day of MR1's transfer. This information was discovered on the facility's review of MR1.

3) Review of MR1 on April 29, 2015, revealed this patient was transferred to an outside hospital on April 25, 2015, for further assessment and treatment for substance abuse. Further review of MR1's medical record revealed the facility did not obtain a physician's order for transfer of this patient before transferring to outside receiving hospitals.

Review of MR6 on April 29, 2015, revealed this patient was transferred to an outside hospital on August 31, 2014, for further assessment and treatment. Further review of MR6's medical record revealed the facility did not obtain a physician's order for transfer of this patient before transferring to outside receiving hospitals.

Review of MR9 on April 29, 2015, revealed this patient was transferred to an outside hospital on September 13, 2014, for further assessment and treatment. Further review of MR9's medical record revealed the facility did not obtain a physician's order for transfer of this patient before transferring to outside receiving hospitals.

Review of MR10 on April 29, 2015, revealed this patient was transferred to an outside hospital on March 19, 2015, for further assessment and treatment. Further review of MR10's medical record revealed the facility did not obtain a physician's order for transfer of this patient before transferring to outside receiving hospitals.

Review of MR11 on April 29, 2015, revealed this patient was transferred to an outside hospital on April 2, 2015, for further assessment and treatment. Further review of MR11's medical record revealed the facility did not obtain a physician's order for transfer of this patient before transferring to outside receiving hospitals.

Review of MR12 on April 29, 2015, revealed this patient was transferred to an outside hospital on April 7, 2015, for further assessment and treatment. Further review of MR12's medical record revealed the facility did not obtain a physician's order for transfer of this patient before transferring to outside receiving hospitals.

Review of MR14 on April 29, 2015, revealed this patient was transferred to an outside hospital on April 23, 2015, for further assessment and treatment. Further review of MR14's medical record revealed the facility did not obtain a physician's order for transfer of this patient before transferring to outside receiving hospitals.

Review of MR15 on April 29, 2015, revealed this patient was transferred to an outside hospital on April 22, 2015, for further assessment and treatment. Further review of MR14's medical record revealed the facility did not obtain a physician's order for transfer of this patient before transferring to outside receiving hospitals.

Review of MR18 on April 29, 2015, revealed this patient was transferred to an outside hospital on August 21, 2014, for further assessment and treatment. Further review of MR18's medical record revealed the facility did not obtain a physician's order for transfer of this patient before transferring to outside receiving hospitals.

Interview with EMP1 and EMP2 on April 29, 2015, at approximately 3:00 PM confirmed the facility transferred MR1, MR6, MR9, MR10, MR11, MR12, MR14, MR15 and MR18 to outside hospitals for further assessment and treatment and that these medical records did not contain a physician's order for transfer of these patients before transferring them to outside receiving hospitals.