HospitalInspections.org

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Based on observations, interviews, review of patient medical records, review of policies and procedures and other documents, it was determined that the hospital failed to comply with all requirements of 489.24.

Refer to citations and examples at:

A 2402 (489.20(q) Required Signage - Failure to ensure that signs specifying the rights of individuals to receive examination and treatment for emergency medical conditions and women in labor was conspicuously posted in areas likely to be noticed by individuals entering or receiving treatment in the emergency department.

A 2409 §489.24(e)(2)(ii), Failure to assure that the receiving facility has agreed to accept the patient, has space and qualified personnel available for the treatment.
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Based on observation and review of hospital policy, it was determined that the hospital did not post notices that the hospital participated in the Medicaid program in all areas where the signage was likely to be noticed by individuals waiting for examination and treatment.

Failure to post the notice of hospital participation in the Medicaid program could deprive patients of their right to seek care.

Findings included:

1. Record review of the policy and procedure titled, "Application of and Compliance with the Emergency Medical Treatment and Labor Act (EMTALA)," policy #COMP.301, reviewed 12/22/2016, showed that UW Medicine hospitals shall post signs in conspicuous locations likely to be noticed by individuals entering the DED [dedicated emergency department], labor and delivery areas and other areas where patients are screened including treatment areas.

2. On 05/15/19 starting at 9:45 AM, Investigator #13692 and investigator #19812 toured the Obstetrical (OB) Unit with the OB Nurse Manager (Staff #1). Observations during the tour showed that three (3) unoccupied rooms, #212, #213 and #219 did not have posted signage regarding the hospital's participation in the Medicaid program.

An interview with the OB Nurse Manager (Staff #8) by Investigator #19812, at the time of the observation, showed that the OB unit did not have rooms used exclusively for triage of OB patients but any Labor/Delivery/Recovery/Postpartum (LDRP) could be used for this purpose. The OB Nurse Manager confirmed that the LDRP rooms lacked the required signage.

3. On 05/15/19 starting at 10:00 AM, Investigator #13692 and investigator #19812 toured the Emergency Department (ED) with the Director of ED Services (Staff #8). Observations during the tour showed that:

-The only triage room in the ED did not have posted signage regarding the hospital's participation in the Medicaid program.

-5 unoccupied treatment rooms (#10, #11, #12, #13, and #15) did not have posted signage regarding the hospital's participation in the Medicaid program.

The Director of ED Services confirmed the investigator's observations at the time of the tour.

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Based on interview, review of medical records and review of policy, it was determined that the hospital failed to ensure an appropriate and safe transfer for 1 of 8 patients (Patient #2) who were transferred to other facilities.

Failure to assure a safe and appropriate transfer places patients at risk for unmet care needs.

Reference:
§489.24(e)(2)(ii), the receiving facility has agreed to accept the patient, has space and qualified personnel available for the treatment;

Findings included:

1. Review of the hospital's EMTALA policy COMP.301. last reviewed 12/22/2016, on page 4, showed the following directive that when a patient is transferred the consent of the receiving hospital to accept the transfer must first be obtained and documented in the medical record.

2. Record review of Patient #2's medical record showed:

-Patient #2 was detained in the field by the Designated Crisis Responders (DCR) and was involuntarily detained. The Patient was transported to the Emergency Department (ED) on 05/02/19 at 6:06 PM for medical evaluation and clearance.

-The physician performed a Medical Screening Examination on the patient.

-The patient was discharged from the ED on 05/03/19 at 8:41 AM and sent to a psychiatric hospital.

-The psychiatric hospital returned the patient to UWNW ED on 05/03/19, at an unknown time, because the psychiatric hospital had not officially accepted the patient, and would not have a receiving physician and an available bed until the following morning.

3. On 05/16/19 at 2:15 PM, during an interview with Investigator #13692, the Operations Manager (Staff #11) confirmed the findings found in Patient #2's medical record.