HospitalInspections.org

Based on medical record (MR) review, document review and interview, it was determined that in 1 (patient #1) of 23 MRs reviewed of patients who presented to the hospital requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide a medical screening exam and an appropriate transfer.

Findings include:

1. See findings cited at 489.24(1) A2406 and 489.24(e) A2409.

Based on interview and document review, the facility failed to maintain a central log on each individual who comes to the emergency department, seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for 1 of 23 individuals presenting to the Emergency Department (patient #1).

Findings include:

1. Review of facility documentation written by staff #45, a RN, indicated the following: "On 05-26-11 at approximately 2 a.m., a young man was brought to [the facility] by 2 friends and presented himself at the triage area of the ED...He immediately said he did not want to be seen he just had some questions to ask. He then showed me his hand and asked if I thought it was broken. His hand had some swelling and was tender to touch. I replied saying there was no way to tell without an xray. He then asked if there was anywhere...that he could be seen tonight for some problems he was having. I asked what type of problems he meant and he replied that he is sort of in a toss up right now."

2. Review of patient #1's MR indicated that on 05-26-11 at 0207 hours that the facility's ambulance service picked up the patient at the facility's lobby to transport the patient to facility #2 for evaluation of psychological issues and evaluation of left side chest pain related to possible cracked ribs and swollen right hand due to being involved in a fight.

3. Review of the Emergency Department Patient Log Book lacked documentation that patient #1 was recorded as presenting to the facility Emergency Department on 05-26-11 and the disposition of the patient.

4. On 06-14-11 at 1200 hours, staff #44 confirmed that patient #1's visit to the Emergency Department was not documented in the Emergency Department Log Book.

5. In interview on 06-14-11 at 1155 hours, staff #44 indicated that the facility recognized the EMTALA violation refarding the ER log and as a result, required that starting on 05-30-11 all Emergency Department RNs and Paramedics would have to complete the EMTALA training on the facility's Net Learning within 30 days.

6. Review of staff #45's personnel file indicated that he/she successfully completed the EMTALA training on Net Learning on 06-02-11.

Based on interview and document review, the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed for 1 of 23 individuals who presented to the Emergency Department (Patient #1).

Findings include:


1. Review of facility documentation written by staff #45, a RN, indicated the following: "On 05-26-11 at approximately 2 a.m., a young man was brought to [the facility] by 2 friends and presented himself at the triage area of the ED...He immediately said he did not want to be seen he just had some questions to ask. He then showed me his hand and asked if I thought it was broken. His hand had some swelling and was tender to touch. I replied saying there was no way to tell without an xray. He then asked if there was anywhere...that he could be seen tonight for some problems he was having. I asked what type of problems he meant and he replied that he is sort of in a toss up right now."

2. Review of patient #1's MR indicated that on 05-26-11 at 0207 hours that the facility's ambulance service picked up the patient at the facility's lobby to transport the patient to facility #2 for evaluation of psychological issues and evaluation of left side chest pain related to possible cracked ribs and swollen right hand due to being involved in a fight.

3. There was no written evidence that a medical screening exam was performed by a physician and/or other qualified practitioner on patient #1.

4. There was no documentation to indicate patient refused exam or treatment at time of presentation to facility's ED.

5. On 06-14-11 at 1155 hours, staff #44 indicated that the facility recognized the EMTALA violation regarding medical screening and required that starting on 05-30-11 all Emergency Department RNs and Paramedics have to complete the EMTALA training on the facility's Net Learning within 30 days and confirmed that a new policy/procedure for EMTALA was developed and implemented.

6. Review of staff #45's personnel file indicated that he/she successfully completed the EMTALA training on Net Learning on 06-02-11.

7. Review of the new policy/procedure EMTALA, indicated the following:
"Policy: Under EMTALA, a dedicated emergency department must:
Provide appropriate medical screening to anyone seeking emergency services (this applies when the patient presents to the Emergency Department or anywhere else on the hospital property).
This policy/procedure was created on 06/6/11.

Based on medical record (MR) review, document review and interview, the facility failed to follow its policy/procedure on patient transfers to another facility and failed to provide an appropriate transfer for 1 of 8 Emergency Department (ED) patients transferred to another facility in that the facility lacked documentation of a written request for transfer, lacked documentation of a signed physician certification which included risk and benefits, lacked documentation of communication with the receiving facility to indicate that the facility had accepted the patient and lacked any evidence that the required MR information was sent to the receiving facility for (Patient #1).

Findings include:

1. Review of patient #1's MR indicated that on 05-26-11 at 0207 hours that the facility's ambulance service picked up the patient at the facility's lobby to transport the patient to facility #2 for evaluation of psychological issues and evaluation of left side chest pain related to possible cracked ribs and swollen right hand due to being involved in a fight.

2. Review of facility documentation by staff #45, a RN, indicated the following: "On 05-26-11 at approximately 2 a.m., a young man was brought to [the facility] by 2 friends and presented himself at the triage area of the ED... He immediately said he did not want to be seen he just had some questions to ask. He then showed me his hand and asked if I thought it was broken. His hand had some swelling and was tender to touch. I replied saying there was no way to tell without an xray. He then asked if there was anywhere...that he could be seen tonight for some problems he was having. I asked what what type of problems he meant and he replied that he is sort of in a toss up right now."

3. There was no written evidence that the ED MD and patient signed the Patient Transfer Form #5064635 CP. There was no documentation of a written request for transfer by patient #1 or by a legally responsible person acting on behalf of patient #1. There was no evidence of a signed physician certification documenting risks and benefits. There was no documentation of patient condition on disposition of ED physician communicating with the receiving facility, that the receiving facility had accepted patient and that the required documentation was sent to the receiving facility.

4. Review of policy/procedure Immediate Transfer of Patients to Another Facility, indicated the following:

"Implementation:
1. Inform patient and family/significant other of need to transfer.
3. Complete all physicians' orders prior to transfer and any orders from receiving facility.
4. The physician initiating the transfer makes contact with the receiving facility including confirmation of acceptance and transfer arrangements of the patient. There must be physician to physician communication.
5. All pertinent information should accompany the patient; i.e., x-rays, lab results, chart copy, transfer forms.
6. Fill out transfer forms appropriately"
This policy/procedure was last reviewed/revised on 04/11.

5. In interview on 06-14-11 at 1200 hours, staff #44 indicated that he/she told staff #45 that this was probably an EMTALA violation and did one on one education with staff #45 why it was an EMTALA violation. Staff #44 indicated that starting on 05-30-11, all Emergency Department RNs and Paramedics have to complete the EMTALA training on the facility's Net Learning within 30 days.

6. Review of staff #45's personnel file indicated that he/she successfully completed the EMTALA training on Net Learning on 06-02-11.

7. Review of patient #1's MR from facility #2 indicated the patient arrived to facility #2 via facility #1's ambulance on 05-26-11 at 0300 hours for psychiatric evaluation and complaint of left rib pain and right hand pain. The patient was given a medical screening exam by facility #2's ED physician and psychiatric services and the patient was admitted for observation for a mood disorder and further discharge planning due to patient being homeless.