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ATRIUM HEALTH UNION 600 HOSPITAL DR MONROE, NC 28112 March 7, 2019
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on hospital policy review, medical record review, and physician interview the hospital failed to comply with 42 CFR 489.20 and 489.24.

The findings included:


1. The hospital's Dedicated Emergency Department (DED) failed to provide a written physician certification for 2 of 7 sampled transferred patients to other facilities with emergency medical conditions (#31 and #5).

~ Cross refer to 489.24(e)(1)(ii) - Appropriate Transfer - Tag A2409
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record reviews, and physician interviews, the hospital's Dedicated Emergency Department (DED) failed to provide a written physician certfication for 2 of 7 sampled transferred patients to other facilities with emergency medical conditions (#31 and #5).

The findings included:

Review of the "EMTALA COMPLIANCE, INCLUDING PATIENT TRANSFERS..." policy, reviewed/revised 05/2018, revealed "...
IV. Transfer of Unstabilized Individual for Medically Indicated Reasons: ....(2) The physician certifies in writing that the expected benefits of the transfer outweigh the increased risks of transfer to the individual....The physician must sign a certification. The (name) EMTALA Transfer Form, serves as the certification of transfer as required by EMTALA. (a) The emergency physician/on-call physician will complete and sign the (name) EMTALA Transfer Form.... (b) A summary of the risks and benefits upon which this conclusion was based will be documented in the (name) EMTALA Transfer Form. (c) If the physician is not physically present to sign the (namae) EMTALA Transfer Form at the time of transfer, the QMP may sign it after consulting with the physician and confirming his/her agreement to transfer. The physician must countersign the (name) EMTALA Transfer Form as soon as practicable after the transfer. ..."

1. DED record review revealed Patient #31 arrived on 02/01/2019 at 1559 after a bicycle accident. Review of the PA (Physician Assistant) Provider Note, time seen 02/01/2019 at 1608 revealed Patient #31 was a 6 year old who presented for evaluation " ...after he accidentally crashed his bicycle into a tree prior to arrival. He was going down a hill, he was not wearing a helmet. He did hit is head, he did not lose consciousness. No altered mentation, nausea, vomiting since. He mainly complains of pain to his right thigh. He does endorse having pain to his head as well, denies any abdominal pain, chest pain, shortness of breath. Denies any neck or back pain. No distal motor or sensory deficits. ..." Provider Note review revealed "...Medical Decision Making... On exam he is fully neurologically intact, he is GCS of 15. He does have obvious deformity to his right thigh, however there is no break in overlying skin. He is neurovascular intact distally .... Did obtain basic labs, obtain plain film of chest, pelvis and right femur. Imaging significant for midshaft femur fracture. Patient was placed in a traction splint for this. Repeat neuro exams normal throughout ED stay., his (sic) hemodynamically stable throughout ED stay. Did discuss with (MD name) who did evaluate the patient. patient will be transferred to the (name of children's hospital) for trauma evaluation and further mgmt. Did discuss with Dr. (name) Dr. Peds ED attending who accepted patient for transfer. ..." Review revealed the Provider Note was electronically signed by the PA on 02/01/2019 at 1821 and electronically signed by the MD on 02/02/2019 at 0309. Review of the DED medical record did not reveal a transfer form. DED record review revealed a "Transfer & Transport Request", entered at 1644 by a Physician Assistant, which stated the transfer was for a "Higher level of care" but did not note any risks of transfer. DED review also revealed a "Transfer and Transport MD Certification", entered at 1709 by a RN, that indicated a receiving facility and physician were obtained, noted a statement that the medical necessity was " ...continuity of care, and noted the patient was being transported by ground ambulance. R (right) leg traction/splint." Review of the document "Transfer and Transport MD Certification" did not reveal a physician signature. Review of vital signs revealed vital signs at 1825 included Pulse 118, Blood Pressure 123/78 and pulse oximetry of 98%. DED record review of "HandOFF Communication - Transport" revealed a report was given by the RN to Transport and a call was made to the receiving hospital at 1832. Further DED record review revealed Patient #31 was transferred at 1833. Record review did not reveal any further notations related to the transfer. Review of the electronic medical record did not reveal any notation of discussion of the risks of transfer. Electronic review did not reveal a completed Transfer Form to include a specific certification signed by the physician that included the risks of transfer.

Interview with the Accreditation Manager on 03/07/2019 revealed the PA who treated Patient #31 was not available for interview.

Interview with the DED Nurse Manager, on 03/07/2019 around 1545, revealed the transfer form is electronic and has to be printed manually. If it was not printed at the time of transfer, interview revealed, it could not be printed now to show what was reviewed or noted.

Telephone interview with MD #3, on 03/07/2019 at 1150 revealed the transfer form was a printable form and does not print out until all is completed and the ambulance takes the patient. Interview revealed MD #3 recalled seeing Patient #31 concurrently with the PA. Interview revealed typically MD #3 reviewed the risks and benefits of transfer, but stated the PA was filling out the form.




2. Review of the closed DED medical record on 03/05-06/2019 for Patient #5 revealed a [AGE] year old male brought into the DED on 02/10/2019 at 2345 with law enforcement and involuntary commitment (IVC) paperwork, for violence towards family. Review of the triage nursing notes revealed Patient #5 was an acuity of 2 (Emergent). Review of the triage vital signs revealed temperature 99.7, pulse 106, blood pressure 126/76, oxygen saturation 99% and respirations 22. Review revealed the MSE was initiated at 2355 on 02/10/2019. Review of provider notes documented at 0100 on 02/11/2019 revealed " ...The patient is a [AGE]-year-old with a history of oppositional defiant disorder who comes to the emergency department in the custody of Sheriff's as his mother is filing involuntary commitment paperwork with the magistrate. The patient was in argument with his mother tonight. Additionally, he cut his sister's arm with a knife. He has a history of self-harm. The (sic) does not appear to be any acute medical concerns. He will require telemetry psychiatrist evaluation for further risk assessment and treatment management options..." Review revealed Patient #5 was moved to the behavioral health holding unit on 02/11/2019 at 0202. Review revealed Patient #5 was seen by telepsychiatry on 02/11/2019 at 0851. Review of the telepsychiatrist note revealed "...Assessment: Rec (recommend) admit to IP (inpatient) care. Mom preferred local only. He has presented after a severe violent outburst in home where he put mom in a choke hold and cute his sister with a knife..." Review revealed Patient #5's IVC was reviewed and continued. Review revealed Patient #5 stayed in the behavioral health holding unit while waiting for an inpatient psychiatric bed. Review revealed Patient #5 saw the telepsychiatrist again on 02/17/2019 at 1203. Review of the note revealed " ...[AGE]-year-old male with mood unstable disorder and oppositional as well as parent-child conflict ...The mother is still wanting inpatient stabilization ...No changes in medication ..." Review of a DED physician note dated 02/19/2019 at 0620 revealed " ...[AGE] year old male is IVC and awaiting placement at a facility. He will continue to be monitored in the ED. No acute issues ..." Review of a nursing progress note revealed "Bhpp (behavioral health patient placement) contacted ...(RN Name) ...patient is accepted at (name of inpatient psychiatric facility) ...accepting physician (name of accepting physician) ...number to report (phone number) ..." Review of the "EMTALA TRANSFER FORM" revealed a line which stated "Transferring Physician Electronic Signature: (PA #1) Date/Time: 02/19/19-1808". Further review revealed a line which stated "I certify patient is appropriate for transfer and the expected benefits of transfer outweigh the risk close to the time of transfer ..." with PA #1's signature and the date/time of 02/19/2019 at 1810. Review revealed no physician signature electronically or physically on the transfer form. Review revealed no note written by PA #1 or the supervising physician of PA #1. Review revealed Patient #5 was transferred to an inpatient psychiatric unit with law enforcement on 02/19/2019 at 1830.

Interview on 03/06/2019 at 1515 and 1730 with PA #1 confirmed it was his signature on the "EMTALA TRANSFER FORM" for Patient #5. Interview revealed PA #1 did not recall Patient #5. Interview revealed usually the physician would sign the transfer form, but if the physician was busy, PA #1 would review the patient's chart, look at the most recent vital signs, sign the transfer form and transfer the patient. Interview revealed the PA would "check-in" with the physician afterward and notify them of the transfer. Interview revealed the physician would then co-sign the form electronically. Interview revealed PA #1 would usually write a note about the transfer and confirmed there was not a note in Patient #5's chart about the transfer, stating "there is a gap in this case." Interview revealed it was a rare occurrence for PA #1 to sign the transfer form.

Interview on 03/06/2019 at 1545 with MD #1 revealed he was the overseeing physician for PA #1 on 02/19/2019. Interview revealed MD #1 did not recall Patient #5. Interview revealed normally the physician would sign the transfer form. Interview revealed MD #1 would not always write a note about the transfer, since Patient #5 had been waiting for an inpatient psychiatric bed for days the physicians are only required to write a daily note. Interview revealed it was rare for the physician assistants or nurse practitioners to sign a transfer form, usually the physician would sign it. Interview revealed MD #1 did not remember Patient #5 so did not know if PA #1 talked to him about the transfer. Interview revealed MD #1 had never signed a transfer form after a physician assistant, he would usually do the transfer form himself.

NC 689