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Based on observation, interview and document review, the hospital failed to post conspicuously in the emergency department as well as the patient waiting area, patient examination area and patient treatment area, a sign specifying the rights of the individuals with respect to examination and treatment for emergency medical condition and women in labor.

Findings:

On 5/19/11 at 4:15 P.M., a tour and evaluation of the Emergency Department of the hospital was conducted with the administrator and director of nursing services.

The hospital provision for posting of signs in accordance with the regulatory requirement for Emergency Medical Treatment and Active Labor Act (EMTALA) was evaluated during the tour. A posting/signage was observed at the public entrance leading to the unit. The posting of conspicuous signs were not provided in the patient admitting area, examination and treatment rooms.

The posting is required to provide public information relative to the person's rights to receive, within the capabilities of the hospital's staff and facilities the following: appropriate medical screening examination, necessary stabilizing treatment, and if necessary, an appropriate transfer to another facility even if you cannot pay, do not have medical insurance or if entitled to Medicare or Medi-Cal. The posting should also include the information about the hospital's participation in the Medi-Cal program.

The facility administrator acknowledged the lack of the required posting during the unit tour and indicated that the posting will be provided to include the above areas.

Based on interview, record review and review of the facility policy and procedure, the hospital failed to ensure permission to accept the transfer of 1 of 1 sampled patients (Patient 25), with an emergency medical condition, was obtained from the receiving hospital prior to the patient's transfer. The failure to fulfill this is in violation of a regulatory requirement specific to Emergency Medical Treatment and Active Labor Act (EMTALA).

Findings:

Patient 25 was admitted to the Emergency Department (ED) of the hospital for mental health evaluation and treatment, on May 9, 2011 at 10:35 A.M. The patient was brought in by law enforcement officers in response to a public complaint about the patient's agitation, wandering in other people's yard and making demands for the owner to leave the house.

On 5/09/11 at 11:20 A.M., a registered nurse (RN 1) documented that the patient was evaluated by the physician. Two medications were ordered and given to control the patient's agitation. At 5:28 P.M., a licensed vocational nurse (LVN 2) documented that the patient's blood sugar level was checked and the result was high at 600 (normal reading is 70-110). The nurse documented that he notified the physician of the patient's high blood sugar reading. The nurse also documented about the "plan" to send the patient to Hospital A for evaluation and treatment. He indicated that a report was given to a male nurse (no name specified) at Hospital A Emergency Department (ED). The patient was sent to Hospital A by ambulance transport at 6:14 P.M. on 5/09/11.

On 5/19/11 at 2:05 P.M., an initial investigation was conducted in response to the facility reporting to CMS (Federal Agency), that the facility had erroneously transferred a patient with an emergency medical condition, to Hospital A instead of Hospital B, as ordered by the patient's physician.
An interview with the assistant administrator (AA) was conducted on 5/19/11 at 2:10 P.M. The assistant administrator confirmed that this incident occurred. The AA indicated that the facility physician had called the ED of Hospital A to arrange for the patient's transfer, but was told that the hospital was on "bypass," and that, the facility no longer had a contract with Hospital A to accept the patient. There was no documentation to reflect the name of the receiving ED physician who was spoken to, and no documentation of his or her acceptance of the patient's transfer, nor the date and time of the conversation. It was confirmed through interview and record review, that Patient 25 was transferred to Hospital A without the receiving hospital's and/or ED physician's agreement to accept the patient's transfer.

On 5/19/11 at 2:45 P.M., a joint review of the patient's medical record was conducted with the AA. The record contained a document titled "Emergency Transfer Summary," and was dated 5/09/11, 5:20 P.M. The document was completed and signed by Patient 25's physician.
The record revealed the physician's certification that the patient required a higher level of care, as well as the patient's acceptance of the transfer and the patient's condition at the time of transfer. The document also included the name of another hospital (Hospital B) that the patient was being transferred to, including the name of the accepting physician and the time that the patient was accepted by the physician. This information was also supported by another physician's order, dated 5/09/11 at 5:15 P.M., to transfer Patient 25 to Hospital B. It was determined at a later time however, that LVN 2 erroneously transferred Patient 25 to Hospital A, instead of Hospital B, as ordered by the physician.

On 5/09/11 at 3:05 P.M., an interview was conducted with LVN 2. He stated that he was the person who arranged for the patient's transfer. He stated that he thought he heard from the physician that the patient was to be transferred to Hospital A. When questioned if he checked and validated the physician's order regarding the patient's transfer to Hospital B, LVN 2 confirmed that he did not read the physician's order or the transfer summary record, as completed and signed by the physician. LVN 2 stated that he assumed that the patient was being transferred to Hospital A.

When LVN 2 was interviewed regarding the training he had received relative to EMTALA requirements, he stated that had not received the formal training. Review of LVN 2's training record confirmed that LVN 2 had worked regularly in the Emergency Department of the facility, but had no documented in-service training related to the facility's policy and procedures regarding EMTALA requirements. The AA confirmed that it was the facility's policy to provide EMTALA training to all nursing staff, particularly staff that are assigned to work in the Emergency Department of the facility.

On 5/24/11 at 4:17 P.M., an interview was conducted with Physician 1 who evaluated Patient 25 and completed the Emergency Transfer Summary Record, and wrote the order to transfer the patient to Hospital B. Physician 1 stated that prior to transferring the patient, she had spoken to a female physician (no name documented) at Hospital A about the patient's transfer. She was informed however, that Hospital A had 15 patients in the waiting room, and that the "contract (transfer agreement with the facility) had expired," and that Hospital A was not able to accept the patient's transfer. Physician 1 then called another hospital (Hospital B) and spoke to "a physician" who accepted the patients' transfer.

Physician 1 had also indicated during the interview that she was unaware that Patient 25 was transferred to Hospital A instead of Hospital B as she had ordered. Physician 1 did find out later at about 10:00 P.M. on 5/9/11, when she received a call from an ED physician at Hospital A. She did not understand why an ED physician from Hospital A would be calling her about a patient that she had ordered to be transferred to Hospital B. Physician 1 then asked the ED physician how the patient could have ended at their facility. She received no clear answer. She then thanked the ED physician at Hospital A for treating and clearing the patient. Patient 25 was transferred back to the facility on 5/09/11 at 10:04 P.M.

A review of the facility's policy and procedure relative to transfer protocol for EMTALA was conducted. The policy included a statement whereby EMTALA would be applicable to any individual who came to the facility's specialty care unit seeking examination or treatment for a medical condition. And that, a patient with an unstabilized medical condition may be transferred only if the hospital complied with the policy that the receiving hospital and the physician had agreed to accept the patient and provide the appropriate medical treatment.

In summary, the nursing staff failure to read and validate the physician's certification and order for the patient's transfer, resulted in the patient being transferred to the wrong hospital, which had no prior agreement to accept the patient. The transfer of Patient 25 without the physician certification validating Hospital A and the ED physician's agreement to accept and treat the patient, was in violation of the facility's policy on emergency transfer of patients.