HospitalInspections.org

Based on medical record (MR) review, document review and interview, it was determined that in 1 (patient #MR100) of 20 MRs reviewed of patients who presented to the hospital requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide a medical screening exam, stabilizing treatment and an appropriate transfer.

Findings include:

1. See findings cited at 489.24(r) and 489.24(c), A2406, 489.24(d)(1-3), A2407 and 489.24(e)(1)-(2), A2409.

Based on document review and interview, the facility failed to maintain a medical record for one (1) of eight (8) emergency department (ED) patients transferred to another acute care facility (#MR100).

Findings include:

1. Review of #T1's ambulance service Patient Care Report dated 6-3-11 for #MR100 indicated patient "was brought to" #F1's "E/R ramp..."

2. Review of ED medical record listing for the month of June 2011 indicated there was no medical record for #MR100.

3. At 1130 on 07/14/11, #A1, #A2, #A3 and #A4 indicated there was no medical record for #MR100.

Based on document review and interview, the facility failed to maintain a central log on each individual who comes to the emergency department, seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for 1 of 20 individuals presenting to the Emergency Department (patient #MR100).

Findings include:

1. Review of #T1's ambulance service Patient Care Report dated 6-3-11 for #MR100 indicated patient "was brought to" #F1's "E/R ramp..."

2. Review of the central log for 06/03/11 indicated #MR100 had not been entered upon presentation to the ambulance bay.

3. At 1130, #A2 and #A4 confirmed that #MR100 had presented to emergency department on 06/03/11 and had not been entered on the central log.

4. Review of policy/procedure Emergency Medical Treatment and Active Labor Act, CC 1.07 indicated:

"II. Medical Screening Examination

B......the individual's triage classification will be indicated on the Central Log.

C.

1. All individuals presenting to a dedicated emergency department are to be logged in the Central Log.....log must note the disposition...., whether he/she refused treatment.....The central Log shall also include any patient who leaves before being triaged and/or registered. If no demographic data was obtained from the patient, an entry should be made in the Central Log with a brief description of the patient, including an estimated age".

Based on document review and interview, the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed for 1 of 20 individuals who presented to the Emergency Department (patient #MR100).

Findings include:

1. Review of #T1's ambulance service Patient Care Report dated 6-3-11 for #MR100 indicated patient "was brought to" #F1's "E/R ramp..."

2. There was no medical record or documentation to indicate a medical screening exam was provided for #MR100 or that the patient refused care at the time of presentation to #F1's emergency department.

3. On 07/14/11 at 1230 hours, staff #S5 indicated #F1 had received a telephone call on 06/03/11 (Friday) from #T1 regarding transport of a patient with chest pain 9 of 10. Patient requested to be transported to #F3, but due to patient condition (chest pain, blood pressure 83/50, irregular pulse, cardiac history), transport would be to closest facility, #F1.

4. #A1, #A2, #A3 and #A4 confirmed that the sequence of events should have been documented at the time.

5. Review of policy/procedure Emergency Medical Treatment and Active Labor Act, CC 1.07 indicated:

"II. Medical Screening Examination

A. When an individual comes to the Emergency Department with an Emergency medical Condition, facilities are obligated to perform a medical screening examination if an emergency medical condition exists".

Based on document review and interview, the facility failed to ensure stabilizing treatment was provided to one (1) of twenty (20) patients presenting to the Emergency department (ED), #MR100.

Findings include:

1. Review of #T1's ambulance service Patient Care Report dated 6-3-11 for #MR100 indicated patient "was brought to" #F1's "E/R ramp..."

2. There was no medical record or documentation of a written refusal of exam and/or treatment by #MR100.

3. On 07/14/11 at 1230 hours, staff #S5 indicated #F1 had received a telephone call on 06/03/11 (Friday) from #T1 regarding transport of a patient with chest pain 9 of 10. Patient requested to be transported to #F3, but due to patient condition (chest pain, blood pressure 83/50, irregular pulse, cardiac history), transport would be to closest facility, #F1.

4. #A1, #A2, #A3 and #A4 confirmed that the sequence of events should have been documented at the time.

6. Review of policy/procedure Emergency Medical Treatment and Active Labor Act, CC 1.07 indicated:

"III. Stabilization and Transfer to Another Facility

A. If an individual comes to the dedicated emergency department or hospital property and has an emergency medical condition, the facility must provide either:

1. Further medical examination and treatment.....as required to stabilize the medical condition....."

Based on document review and interview, the facility failed to follow its policy/procedure on patient transfers to another facility and failed to provide an appropriate transfer for 1 of 8 Emergency Department (ED) patients transferred to another facility in that the facility lacked documentation of a written request for transfer, lacked documentation of a signed physician certification which included risks and benefits and lacked any evidence that the required MR information was sent to the receiving facility for patient #MR100.

Findings include:

1. Review of #T1's ambulance service Patient Care Report dated 6-3-11 for #MR100 indicated patient "was brought to" #F1's "E/R ramp..."

2. On 07/14/11 at 1230 hours, staff #S5 indicated #F1 had received a telephone call on 06/03/11 (Friday) from #T1 regarding transport of a patient with chest pain 9 of 10. Patient requested to be transported to #F3, but due to patient condition (chest pain, blood pressure 83/50, irregular pulse, cardiac history), transport would be to closest facility, #F1. When #MR100 arrived in ambulance bay of #F1, he/she refused to disembark the ambulance, indicating they wanted to go to #F3. After the ambulance left #F1, #S5 telephoned #F2 to inform of patient in transport. #F2 accepted patient. "I did email my nursing manager on 06/07/11 about the situation."

3. There was no physician certificate to indicate risks and benefits of transfer. There was no documented medical treatment minimizing risks and no documentation of records being sent to the receiving facility.

4. There was no written evidence that #MR100 requested transfer, was informed of the facility's obligations under EMTALA and of the risks and benefits of transfer, that the request by the patient for transfer was in writing, including reasons for transfer or the request was part of the medical record and was sent with the individual to the receiving facility.

5. #A1, #A2, #A3 and #A4 confirmed that the sequence of events should have been documented at the time.

6. Review of policy/procedure Emergency Medical Treatment and Active Labor Act, CC 1.07 indicated:

"III. Stabilization and Transfer to Another Facility

D. The facility may not transfer a patient with an emergency medical condition that has not been stabilized UNLESS:

2. The individual.....requests the transfer, after being informed of the facility's obligations under EMTALA and of the risks and benefits of transfer.

Physician Certification. The certification must carry a summary of the risks and benefits upon which it is based.....See Patient Transfer Form-Provider Certification.

E. If the individual.....requests the transfer, the following steps must be taken:

1. The request must be in writing and indicate the reasons for the request.

2. The request must indicate the individual or legal representative is aware of the risks and benefits of the transfer.

3. The request must contain a statement of the facility's obligations under EMTALA and that the benefits and risks were explained to the person making the request.

4. The request must be made part of the medical record and must be sent with the individual to the receiving facility.

7. Review of #MR100 (complainant) at #F2 indicated a 50-year old presenting to #F2's ED on 06/03/11 at 1735 "with complaints of chest pain" triaged as "Emergency".