HospitalInspections.org

Based on document review and interview, it was determined that the facility failed to ensure comprehensive policies were established, documented and implemented to address recipient hospital responsibilities, "code purple" events, and failed to document ED provider to ED provider communication for potential transfers and/or transfer requests. This deficient practice has the potential risk of harm to patients if appropriate EMTALA policies are not developed and implemented as well as appropriate tracking and oversight of ED activities by administrative leadership.

Findings include:

1. The policy titled "Emergency Medical Treatment And Labor Act (EMTALA), last review date 2/2021, last revised date 11/2017" revealed: "...Effect an appropriate transfer for a patient who has a medical condition that exceeds the capability and capacity of the facility. This is to include appropriate medical treatment, within the capability and capacity of the facility, to minimize risk to the individual, arranging for and coordinating the patient transfer by means most appropriate for the patient ' s clinical condition and providing pertinent medical records to the receiving facility so that appropriate care is not delayed...Patient Transfers...In the event the patient's clinical condition exceeds both the capability and capacity of the facility, or the patient or designee requests, and appropriate transfer may be effected if the attending emergency room physician determines that the medical benefits exceed the associated risks...."

The policy titled "Emergency Medical Treatment And Labor Act (EMTALA), last review date 2/2021, last revised date 11/2017" did not address "Recipient Hospital Responsibilities."

A policy that addressed "Recipient Hospital Responsibilities" was requested; however, none was provided.

Employees #5, 6, and 22 confirmed that the hospital EMTALA policy only addressed transfer out of their facility and did not address potential transfers in, nor did it or other facility policies address the hospital's recipient responsibilities.

2. The policy titled "Emergency Medical Treatment And Labor Act (EMTALA), last review date 2/2021, last revised date 11/2017" revealed: "...Central Log...The hospital will maintain a log of all patient who have presented to the hospital and requested emergent medial services....The purpose of the central log is to track the care provided to each potential patient who comes to the hospital seeking care for an emergent medical condition...."

A request for documentation of the facility's ED provider to ED provider calls was requested but not provided.

Employee #22 confirmed on 07/22/2024 that the facility does not track ED provider to ED provider calls with requests to transfer a patient from other hospital ED's to Hospital #1's ED for emergency medical treatment.

3. The policy titled "Code Purple" requires: "...Purpose: To define and provide an alert response when the activity on a patient care area or critical change in patient condition results in a situation that exceeds the unit's capability to provide appropriate patient care...Policy: A Code Purple alert is utilized in the event of a sudden influx of patient activity or change in patient condition that requires additional clinical staff to respond to a patient care area. The Code Purple alert indicates the need to mobilize additional staff to a patient care area to provide short term patient care and assistance to stabilize the patient care environment. This alert does not replace the Capacity Alert Plan, Disaster Plan, Rapid Response Team alert or Code Blue alert...Guidelines: 1. When a rapid change in patient activity or condition exceeds the capability for a patient care unit to safely provide patient care, the Nurse Clinical Leader (NCL) will notify the Administrative Shift coordinator (ASC) of the potential need to activate a "Code Purple"...2. The Administrative Shift Coordinator (ASC) will report immediately to the alerted area and rapidly assess the situation with the NCL. If readily available, additional staff from other resources are allocated to the unit. If it is determined that these resources are not enough to safely meet patient needs, the ASC announces "Code Purple __________(department names)" alert overhead. If the ASC cannot physically respond to the unit, the above is implemented by phone...3. In the event of a "Code Purple" alert, each nursing department will designate a Registered Nurse (RN) to respond to the alert area. The ASC will collaborate with the NCL on the unit in crisis regarding need for additional clinical support staff (ie. Physician, pharmacist, respiratory therapist, social worker, radiology technician, laboratory technician)...4. The NCL on the patient care area in crisis will direct the responders regarding patient care duties according to level of competency...5. In the event the responders are unable to utilize the crisis unit's electronic medical records, paper progress notes are utilized to document patient care...6. The ASC will coordinate movement of patients out of the unit in crisis to other clinical areas as available. Example: move admitted patients out of the Emergency Department (ED) to allow staff to adequately care for higher acuity patients and ease overcrowded waiting room...7. In the event the "Code Purple" alert response is inadequate to stabilize the patient care environment within thirty to sixty minutes, the ASC and NCL will call staff to report from home...8. Enter "Code Purple" alert in incident reporting system...9. All "Code Purple" alerts are reviewed by Nursing Unit Directors to assess responses, appropriateness and recommend future improvement opportunities as deemed necessary...."

Monthly ED staffing schedules dated April, May, June, and July 2024 revealed minimal hand-written notes documenting the following "Code Purple" events on daily schedules as follows:

"...Tuesday April 9, 2024...code purple...1400 (sic) (no stop time noted)...
Monday April 22, 2024...Code purple...1800-2330...
Friday May 3, 2024...Code Purple...1330...end 1730...
Saturday May 11, 2024...Code Purple...12-1500 (sic)...
Friday May 17, 2024...Code purple...1955-0100...
Monday May 20, 2024...Code purple...1800-0030...
Wednesday May 22, 2024...code purple...2320-0600...
Wednesday May 29, 2024...Code purple...2115-0100...
Friday May 31, 2024...Code purple...1800-0100...
Tuesday June 4, 2024...Code Purple...0945-1400...
Saturday June 8, 2024...code purple (start and stop times/notes illegible and unable to determine)...
Wednesday June 12, 2024...code purple...before 1800-about 0000 (sic)...
Saturday June 15, 2024...Code purple...0325- (sic) (no stop time noted)...
Monday July 1, 2024...code purple...till 0100ish (sic) (no start time noted)...
Monday July 8, 2024...Code Purple...1400-1800++ (sic)...
Tuesday July 9, 2024...code purple...1100-0600...
Saturday July 13, 2024...code purple (no start or stop times noted)
Friday July 19, 2024...CODE purple...11-1500 (sic)...."

Each of the above listed code purple events documented on the ED staffing schedules did not contain documented evidence that the facility followed their "Code Purple" policy for nursing leadership notifications, determinations of additional resources and nursing staff allocated to respond to the ED to meet patient needs, movement of admitted patients out of the ED to inpatient areas if possible, any staff called in to help stabilize the patient care environment, documentation of the event in the facility incident reporting system, and documentation of oversight by leadership and an assessment of the response and appropriateness of interventions for the code purple events that occurred.

Documentation of evidence that the facility followed their "Code Purple" policy for nursing leadership notifications, determinations of additional resources and nursing staff allocated to respond to the ED to meet patient needs, movement of admitted patients out of the ED to inpatient areas if possible, any staff called in to help stabilize the patient care environment, documentation of the event in the facility incident reporting system, and documentation of oversight by leadership and an assessment of the response and appropriateness of interventions for the code purple events that occurred was requested.

Employees #6 and 22 confirmed 07/23/2024 on that the ED did not follow the facility policy "Code Purple" for reporting events of an increase in patient activity in the ED or changes in patient conditions that would require additional staff and/or resources to safely provide care in the ED.

Employees #22 confirmed on 07/23/2024 that Patient #21 was not accepted as an ED to ED transfer due to the ED being in "Code Purple" status on 06/12/2024 and that s/he is unaware of how often this may happen as the ED does not track ED provider to ED provider calls and keep detailed documentation of "Code Purple" events as required by facility policy.