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.

Based on a review of facility documentation and medical records (MR) and staff interviews (EMP), it was determined that the facility failed to report to CMS (Center for Medicare Services) or the State within 72 hours of a patient whom the facility believed to be improperly transferred for one of 24 medical records reviewed (MR1).

Findings include:

Review of Facility policy "EMTALA" reviewed September 22, 2014, revealed ".. The Hospital has a duty to report an EMTALA violation within 72 hours to the Centers for Medicare and Medicaid Services and/or the State survey agency any time it has a reason to believe it may have received an individual who has been transferred in an Emergency Medical Condition from another hospital in violation of the requirements."
1) Review of ambulance trip sheet dated July 9, 2015, at 06:45 revealed " [transferring hospital] Medical Command saw patient and request that patient be transferred directly to a trauma. Patient being transported to [receiving hospital]. ...07:40 No change in patient status. Out at [receiving hospital]. ...07:45 Patient care transferred to trauma team. Patient placed in ER bed t17 via board lift. Patient care report given to team at bedside... ."

2) Review of MR1 dated July 9, 2015, revealed no documentation accompanied the patient from the transferring hospital to the receiving hospital. Further review of MR1 also revealed no documentation by physician or nurse that indicated the pateint was seen or treated at another hospital or that pateint was transferred with physician certification or other medical documentation.

3) During interview on September 21, 2015, at approximately 10:00 EMP1 revealed "...The first time we thought we had a problem [EMTALA] was September 1, 2015... ." EMP1 revealed being notified by EMP10 by email on September 1, 2015 that the transferring hospital physician never contacted the receiving hospitals of the imminent transfer.

3) During interview conducted on September 21, 2015, at approximately 13:40 EMP4 confirmed the above findings and revealed when asked if EMP1 knew that the patient was not a direct transfer and was transferred from another hospital EMP1 revealed "yes." When asked if EMP1 suspected the transferring hospital may have improperly transferred the patient according to EMTALA requirements, EMP1 revealed "yes." When asked if EMP1 notified anyone of the potential EMTALA violation EMP1 revealed "yes, physician and trauma folks... ." When asked if she knew whether they reported it to CMS or the State within 72 hours of receiving the patient EMP1 revealed " never went anywhere after that... ."