HospitalInspections.org

Based on document review and interview, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to post EMTALA signs in areas likely to be noticed by all individuals that visit the emergency department (ED), see 2402; and the failure to ensure appropriate transfer of one of nine patients patients reviewed for transfer from a total sample of 21, see 2409.

Based on observation and interview the facility failed to post EMTALA signs in areas likely to be noticed by all individuals that visit the emergency department (ED) resulting in the potential for emergency patients to be uninformed of their rights. Findings include:

On 8/30/16 at approximately 1040 it was revealed during a tour of the ED waiting area the facility failed to have an EMTALA sign that patients entering the facility would be able to see. On 8/30/16 at approximately 1045, staff A was queried as to where the EMTALA signage was located in the ED waiting area. Staff A reviewed the ED waiting area and stated "it used to be located in this area but I'm not sure where it has been moved." On 8/30/16 at approximately 1045 Staff A confirmed the EMTALA signage was not located in the designated ED waiting area.

On 8/30/16 at approximately 1115 further tour of the ED revealed the facility failed to have an EMTALA sign at the entryway of the ambulance entrance where traffic enters through the ambulance bay. Staff B was asked where patients entering the ED via ambulance would see EMTALA information. Staff B stated patient treatment rooms within the ED had EMTALA signage. Three of four treatment rooms (#3, #5, and #13) toured failed to have EMTALA signs. On 8/30/16 at approximately 1130 Staff B confirmed that all rooms did not have EMTALA signage and that signage was missing from the ambulance entry corridor.

Based on document review and interview the facility failed to ensure appropriate transfer for 1 (#21) out of 9 patients reviewed for transfer, from a total sample of 21 patients resulting in the potential for poor patient outcomes. Findings include:

On 8/31/16 at approximately 0920 during medical record review it was revealed that the patient (#21) had visited the emergency department (ED) on 8/7/16 at 1707. The patient had been brought to the ED via ambulance related to passing out and falling on her face after excessive consumption of alcohol. The patient's mother provided the initial intake information to the ED. The patient's mother reported that the patient had stated she was going to kill herself if she had to go to rehab (rehabilitation) again. The patient's mother further stated the patient had been making suicidal comments to her (patient's mother) and to the patient's significant other. The patient's mother also stated that she felt the patient (daughter) was going to harm herself and felt the patient is back to the point that she needed hospitalization and that outpatient therapy was not helping the patient.

The patient was seen by physician K on 8/7/16 at approximately 1730. The decision was made to let the patient sober up from the alcohol intoxication and have the patient evaluated by XYZ County Medical Services (CMH). On 8/8/2016 a repeat alcohol level was obtained and indicated the patient was able to be assessed by the CMH psychologist (Staff L). A petition and certification took place on 8/8/2016 at approximately 1500. The clinical certification stated diagnosis as bipolar type 1 depressive disorder. The facts serving as Staff L's determination were listed as "client has long history of mood swings with issues of poor self worth and thoughts of suicide...has indicated she cannot cope with mood swings and would rather be dead than live this way." According to the medical record the patient was accepted by Hospital B for transfer. Further review of the medical record revealed the medical record failed to contain the date and time the call took place to Hospital B and failed to contain information of the accepting physician at Hospital B.

On 8/31/2016 at approximately 0945 further review of the patient's (#21) medical record failed to show a transfer sheet for the patient. A request for a printed copy of the patient's medical record was made for further evaluation. The medical record failed to contain a transfer sheet. The medical record states that the patient's mother was to provide transfer for the patient stating "Eval (evaluation) by Dr. XXXX (Staff L) and pt (patient) with petition and cert (certification) and mother comfortable transfer hospital B for admission. Per Dr. XXXX (staff L), accepted by hospital B for admission." The departure section of the medical record stated "Dr. XXXX (staff L) with (will) call you when they have a bed for you at psychiatric hospital." The patient was discharged to home on 8/8/16 at 1429.

On 8/31/2016 at approximately 1345 an interview was conducted with staff A. Staff A was asked if the patient (#21) was ever received at hospital B. Staff A responded that she would call hospital B. At approximately 1410 Staff A returned and stated that the patient was never admitted to hospital B. Staff A was queried if she was aware that when a patient is petitioned and certified for psychiatric care and transfer to an accepting facility that hospital A is responsible for the patient until the patient is received at hospital B. Staff A responded she wasn't sure what had happened in this particular case.

On 8/31/2016 at approximately 1400 an interview with physician K took place. Physician K was queried what was the protocol when a patient is petitioned and certified for psychiatric care and a transfer to a psychiatric facility. Physician K stated that a transfer is arranged for the patient. Physician K was also asked if patients who are petitioned and certified are sent home to await placement. Physician K stated the patient would not be sent home but held at the transferring facility until the time that the accepting facility agreed to accept the patient and had placement availability.

On 9/9/2016 at approximately 0900 a request was made at Hospital B for the medical record of patient #21. Staff AA stated they did not have a record of patient #21 as being hospitalized at Hospital B. A review of intake records from the psychiatric unit from 8/6/2016 through 8/13/2016 showed records were received on 8/8/2016 at Hospital B for patient #21 although Hospital B was at full capacity in psychiatric unit on 8/8/2016 through 8/12/2016. Further review of the intake records showed that Hospital B notified the psychologist (Staff L) on a daily basis from 8/8/2016 through 8/10/2016 that they were unable to admit patient #21 due to full capacity at Hospital B's psychiatric unit.

On 9/9/2016 at approximately 1130 an interview was conducted with the manager of the psychiatric unit at Hospital B. The manager was asked if patients were placed on a waiting list when intake information was received on a patient from a facility. The manager responded that patients could not be considered accepted until which time a bed was available and when the psychiatrist at the facility had accepted the patient for placement.

On 9/14/2016 at approximately 1100, the policy titled "Transfer of the acute patient to another facility/EMTALA" dated 9/4/2013, was received from Hospital A. Hospital A failed to provide the policy during survey on 8/31/2016. Per policy:
"The following basic procedural steps will be completed for transfer: a) Prior to transfer, the clinical care provider shall discuss the risks and benefits of the intended transfer and document on the transfer form in the Provider Certification section. b) The E.D. or attending floor physician shall personally contact the accepting physician to verify that he/she will assume care for the patient, and will document the call on the transfer form. c) If the receiving facility is providing the mode of transport for the patient, discussion of the following shall be documented in the patient record: 1.Patient condition, 2. Level of expertise required, 3. Equipment needed." This was not done.