HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 25 patients the hospital failed to ensure compliance with 489.20 (r) (3) in that the hospital failed to maintain an accurate log of patients presenting to the emergency department (ED), failed to ensure compliance with 489.24 (r) and 489.24 (c) in that the hospital failed to provide a medical screening, and failed to ensure compliance with 489.24 (d) (1-3) in that the hospital failed to provide stabilizing treatment. It was determined that for 1 of 11 patients transferred to another acute care facility, the hospital failed to ensure compliance with 489.24 (e) (1)-(2) in that the hospital failed to provide an appropriate transfer. (patient #N1)

Findings include;

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

Based on document review and staff interview, the facility failed to maintain records of all patient transfers for 1 of 25 patients. (patient #N1)

Findings include;

1. Patient #N1 was brought to the facility emergency department (ED) by EMS on 3/31/11 and transferred to facility #2 after arrival. There was no record generated for the patients visit.

2. Review of medical record for patient #N1 at facility #2 indicated the following:
(A) EMS report indicated the patients paperwork directed EMS to take the patient to (facility #2), however "due to the patients condition" the patient was transported to (facility #1) The document states "Was told by charge nurse that Pt can't be seen there because her insurance is only accepted at (facility #2)." The patient was transported to (facility #2).

3. Staff member #2 indicated the following in interview at 1:10 p.m.:
(A) Patient #N1 was not registered or logged in upon arrival to facility #1.
(B) The patient was brought into the ED by EMS. Vital signs were taken but not documented.
(C) The patient was sent to facility #2.
(D) There is no record for the patient's visit on 3/31/11.

4. The facility has implemented a plan of correction that was put into place prior to survey date that included, but was not limited to, staff education on EMTALA with completion date of 4/12/11.

Based on document review and staff interview, the facility failed to maintain an accurate log of patients presenting to the emergency department (E.D.) for 1 of 25 patients. (patient #N1)

Findings include;

1. Patient #N1 was brought to the ED on 3/31/11 by EMS.

2. The facility ED log lacked documentation that patient #N1 was brought to the ED on 3/31/11.

3. Staff member #2 indicated the following in interview at 1:10 p.m.:
(A) Patient #N1 was not registered or logged in upon arrival to the facility.

4. The facility has implemented a plan of correction that was put into place prior to survey date that included, but was not limited to, staff education on EMTALA with completion date of 4/12/11.

Based on staff interview and document review, the facility failed to ensure patients presenting to the emergency department (ED) received a medical screening exam for 1 of 25 patients. (patient #N1)

Findings include;

1. Staff member #2 indicated the following in interview at 1:10 p.m.:
(A) Patient #N1 was brought into the ED by EMS on 3/31/11.
(B) The physician on duty at the time was not notified of the patients arrival and the patient was sent to facility #2.

2. Staff member #5 indicated the following in interview at 5:15 p.m.:
(A) He/she was the house supervisor on duty 3/31/11 and was in the ED when patient #N1 was in the department.
(B) The patient (#N1) was brought by EMS from a LTC facility and EMS said the patient was unstable. The patient was placed in bed #9.
(C) The physician was not contacted of the patients arrival.
(D) Upon direction from the administrator on call (staff member #8), the patient was sent to facility #2.

3. Review of medical record for patient #N1 at facility #2 indicated the following:
(A) EMS report indicated the patients paperwork directed EMS to take the patient to (facility #2), however "due to the patients condition" the patient was transported to (facility #1) The document states "Was told by charge nurse that Pt can't be seen there because her insurance is only accepted at (facility #2) The patient was transported to (facility #2).

4. Review of medical staff bylaws, rules and regulations last approved 3/1/11 indicated the following:
(A) The bylaws state on page 20: "5.1 SCREENING, TREATMENT & TRANSFER 5.1(a) Screening (1) Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition........

5. Facility policy titled "EMTALA GUIDELINES FOR EMERGENCY DEPARTMENT SERVICES" last reviewed/revised 12/08 states beginning on page 1:
? "All patients presenting to (facility #1) Hospital Emergency, Labor and Delivery or Psychiatric Departments and seeking care, or presenting elsewhere on the hospital's main campus and requesting emergency care, must be accepted and evaluated regardless of the patient's ability to pay. In the absence of an actual request for services, if a "prudent layperson" observer would believe, based on the individual's appearance or behavior that the individual needs an examination or treatment for a medical condition, EMTALA still applies and the person must be accepted and evaluated for treatment.
? All patients shall receive a medical screening exam that includes providing necessary testing and on-call services within the capability of the hospital to reach a diagnosis........

6. The facility has implemented a plan of correction that was put into place prior to survey date that included, but was not limited to, staff education on EMTALA with completion date of 4/12/11.

Based on staff interview and document review, the facility failed to provide stabilizing treatment for 1 of 25 patients. (patient #N1)

Findings include;

1. Patient #N1 was brought to the facility on 3/31/11 and did not receive treatment.

2. Staff member #7 indicated the following in interview at 6:00 p.m.:
(A) Patient #N1 was placed in bed #9 and he/she started triage process. Blood pressure was 90's/50's. The patient was lethargic. The patient was not talking.
(B) The house supervisor (staff member #5) came down and said "just stop" and let me call the administrator on call. After checking with the administrator on call, staff member #5 told him/her to send the patient out.

3. Staff member #2 indicated the following in interview at 1:10 p.m.:
(A) Patient #N1 was brought into the ED by EMS on 3/31/11.
(B) The physician on duty at the time was not notified of the patients arrival and the patient was sent to facility #2.

4. Staff member #5 indicated the following in interview at 5:15 p.m.:
(A) He/she was the house supervisor on duty 3/31/11 and was in the ED when patient #N1 was in the department.
(B) The patient (#N1) was brought by EMS from a LTC care facility and EMS said the patient was unstable. The patient was placed in bed #9.
(C) The physician was not contacted of the patients arrival.

5. Review of medical record for patient #N1 at facility #2 indicated the following:
(A) EMS report indicated the patients paperwork directed EMS to take the patient to (facility #2), however "due to the patients condition" the patient was transported to (facility #1) The document states "Was told by charge nurse that Pt cant bee seen there because her insurance is only accepted at (facility #2) The patient was transported to (facility #2).

6. Review of patient #N1 medical record from facility #2 indicated the following:
(A) Per the ED physician record dated 3/31/11, impression was listed as polypharmacy OD, UTI, Rhabdomyolysis, acute renal failure and hyponatremia.
(B) Labs at the time of arrival (10:30 p.m.) indicated several abnormalities including, but not limited to, white count 11.2 (normal 4.8-10.8), myoglobin 7,124 (normal 10.9-93.50), Sodium 132 (normal 135-145), Potassium 5.5 (normal 3.6-5.0), Creatine 2.7 (normal .5-1.2), and Creatine Kinase 1,876 (normal 35-374). The patient also tested positive for Benzodiazepines and Opiates.
(C) The patient was transferred to the intensive care unit (ICU) from the ED.

7. Review of medical staff bylaws, rules and regulations last approved 3/1/11 indicated the following:
"........5.1(b) Stabilization (1) Any individual experiencing an emergency medical condition must be stabilized prior to transfer or discharge, excepting conditions set forth below........(3) A patient does not have to be stabilized when: (i) the patient, after being informed of the risks of transfer and of the hospital's treatment obligations, request the transfer and signes a transfer request form; or (ii) based on the information available at the time of transfer, the medical benefits to be received at another facility outweigh the risks of transfer to the patient, and a physician signs a certification which includes a summary of risks and benefits to this effect...."

8. Facility policy titled "EMTALA GUIDELINES FOR EMERGENCY DEPARTMENT SERVICES" last reviewed/revised 12/08 states beginning on page 1:
? "(facility #1) may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during or after said transfer or discharge. If the patient is at reasonable risk to deteriorate due to the naturel process of their medical condition, they are legally unstable as per EMTALA......
? (facility #1) may not transfer patients who are potentially unstable as long as the hospital has the capabilities to provide treatment and care to the patient. A transfer of a potentially unstable patient to another facility may only be for reason of medical necessity...."

9. The facility has implemented a plan of correction that was put into place prior to survey date that included, but was not limited to, staff education on EMTALA with completion date of 4/12/11.

Based on staff interview and document review, the facility failed to provide an appropriate transfer for 1 of 11 patients transferred to another acute care facility. (patient #N1)

Findings include;


1 In interview with staff member #5 on 4/13/11 at 5:15 p.m., he/she indicated the following:
(A) He/she was the house supervisor on duty 3/31/11 and was in the ED when patient #N1 was in the ED.
(B) The patient (#N1) was brought by EMS from a LTC care facility and EMS said the patient was unstable. The patient was placed in bed #9.
(C) He/she called the administrator on call (staff member #8) and was told to send the patient to facility #2.

2. In interview at 6:00 p.m. on 4/13/11, staff member #7 indicated the following
(A) EMS called in report to him/her prior to the patient arrival.
(B) The patient was placed in bed #9 and he/she started triage process. Blood pressure was 90's/50's. The patient was lethargic. The patient was not talking.
(C) The house supervisor (staff member #5) came down and said "just stop" and let me call the administrator on call. After checking with the administrator on call, staff member #5 told him/her to send the patient out.


3 (A) EMS report indicated the patients paperwork directed EMS to take the patient to (facility #2), however "due to the patients condition" the patient was transported to (facility #1) The document states "Was told by charge nurse that Pt can't be seen there because her insurance is only accepted at (facility #2) The patient was transported to (facility #2).


4. Review of medical staff bylaws, rules and regulations last approved 3/1/11 indicated the following:
(A) The bylaws state on page 20: "..........5.1(c) Transfer (1) The Emergency Department Physician shall obtain the consent of the receiving hospital facility before the transfer of an individual. Said person shall also make arrangements for the patient transfer with the receiving hospital............"

5. Facility policy titled "EMTALA GUIDELINES FOR EMERGENCY DEPARTMENT SERVICES" last reviewed/revised 12/08 states beginning on page 1:
".....If a patient is to be transferred for medical necessity the following guidelines must be followed:
A physician certification that the risks of transferring the patient are outweighed by
the potential benefits. The individual risks and benefits must be documented and the patient's medical record must support these, or
the patient request a transfer in writing.
In addition to the following:
The receiving hospital must give acceptance
in advance. The acceptance must be documented in the medical record;...........

6. There was no documentation of contact with the receiving hospital, no documentation of physicians certification of risks and benefits, no documentation of medical treatment minimizing risk and no documentation of records being sent to the receiving facility.

7. The facility has implemented a plan of correction that was put into place prior to survey date that included, but was not limited to, staff education on EMTALA with completion date of 4/12/11.


8. Review of patient #N1 medical record from facility #2 indicated the following:
(A) Per the ED physician record dated 3/31/11, impression was listed as polypharmacy OD, UTI, Rhabdomyolysis, acute renal failure and hyponatremia.
(B) Labs at the time of arrival (10:30 p.m.) indicated several abnormalities including, but not limited to, white count 11.2 (normal 4.8-10.8), myoglobin 7,124 (normal 10.9-93.50), Sodium 132 (normal 135-145), Potassium 5.5 (normal 3.6-5.0), Creatine 2.7 (normal .5-1.2), and Creatine Kinase 1,876 (normal 35-374). The patient also tested positive for Benzodiazepines and Opiates.
(C) The patient was transferred to the intensive care unit (ICU) from the ED.