Based on findings from document review and interview, the facility did not follow its policies and procedures (P&P) to ensure compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) requirements. The hospital did not accept patients with emergency medical conditions when the hospital had capacity and capability. The hospital did not provide adequate EMTALA education to its staff and the hospital lacked a comprehensive EMTALA P&P. These lapses could lead to untoward patient outcomes. Findings include: -- Review of the hospital's P&P titled "Transfer Center," dated 3/2017, indicated the hospital needs to accept appropriate transfers of individuals with emergency medical conditions if the hospital has specialized capabilities or facilities and has the capacity to treat those individuals. -- Review of Patient #1, #2 and #3's "Regional Transfer Center Intake Forms," dated 9/18/17, 5/13/17, 4/29/17 respectively, indicated the hospital refused to accept the appropriate patient transfers. (See additional findings in Tag 2411) -- Review of the EMTALA education provided to new staff during orientation titled "Patient Transfers," undated, indicated that every patient should be treated regardless of their ability to pay and it discussed transfer of patients to a higher level of care. There was no education pertaining to other EMTALA regulations (e.g., recipient hospital responsibilities, on-call physicians, appropriate medical screening exam, etc.) -- During interview of Staff A (Manager of Nursing Education) on 9/28/17 at 9:40 am, he/she indicated nursing staff only receive EMTALA education at orientation and there are no mandatory yearly updates. -- During interview of Staff B (Emergency Department [ED] Medical Director) on 9/27/17 at 10:00 am, he/she indicated ED providers receive EMTALA education through their malpractice insurance when they first apply. There is no formal hospital training done, however if there is a change in EMTALA regulations staff would be notified. -- Review of the hospital's P&P revealed no evidence of an EMTALA P&P that addressed all the regulations (e.g., Recipient Hospital Responsibilities, On-call Physicians, appropriate medical screening exam, etc.) -- During interview of Staff C (Director of Quality Management) on 9/27/17 at 11:30 am, he/she acknowledged the above findings.

Based on findings from document review and interview, in 3 of 8 referral cases reviewed (Patients #1, #2 and #3), the hospital failed to accept patients, with emergency medical conditions, who required inpatient care despite having specialized services and the capacity to treat the patient. These lapses could lead to untoward patient outcomes. Findings include: -- Review of the hospital's policy and procedure (P&P) titled "Transfer Center," date of origin 3/2017, indicated the hospital needs to accept the appropriate transfer of individuals with an emergency medical condition if the hospital has specialized capabilities or facilities and has the capacity to treat those individuals. The Transfer Center is responsible for coordinating all transfers and expediting appropriate physician contact. The call process is initiated after the sending facility has requested a transfer, indicated the level of care needed and the specialty service required. The Transfer Center Registered Nurse (RN) would then facilitate physician to physician contact via a three way call. After the on-call physician responds the physicians should discuss the case to determine placement, level of care and specialty service required. Once agreed upon the patient is given a room assignment. Cases that are considered emergent needing immediate medical attention on arrival should be considered for Emergency Department (ED) to ED transfer. Due to the nature of surgical cases requiring immediate intervention on arrival it is at the surgeon's discretion to send the patient to the ED verses an inpatient unit. The surgeon is responsible to be in the ED on patient arrival to provide evaluation. -- Review of Patient #1's "Regional Transfer Center Intake Form," indicated on 9/18/17 at 9:34 pm, Hospital A contacted UHS Wilson's Regional Transfer Center regarding the transfer of Patient #1, a [AGE] year old female with an emergency medical condition. Staff D (RN Care Management Transfer Center) documented that Patient #1 had an altered mental status. She was weak, flushed, feverish (Temperature 101.7 degrees fahrenheit), and had a 10 centimeter gluteal abscess. Hospital A had treated Patient #1 with intravenous fluids, Tylenol, and antibiotics. Staff D discussed the patient with Staff E (Hospitalist) at 9:40 pm. -- Per review of an email dated 9/18/17, Staff E asked Staff D to contact the on-call surgeon to see if they wanted to admit Patient #1 to their service or if they would see the patient on consult. The on-call surgeon was paged at 9:51 pm and he/she called the Transfer Center back at 10:13 pm, and stated he/she would not accept the patient. Staff D then contacted Staff F (Director of the Hospitalists), he/she stated Staff E would accept the patient and consult surgery in the morning. Staff D then obtained the bed assignment and notified Hospital A of acceptance. Staff D then received a call from Staff G (on-call surgeon), when asked about Patient #1, he/she informed Staff G that Patient #1 had been accepted by the Hospitalist for admission. After an unpleasant conversation, Staff G was advised to call the Hospitalists to discuss the case. Staff D then received a call from Staff F who indicated, the hospital could not accept the patient because Staff G adamantly refused to see the patient during the night if any urgent surgical intervention was needed and that no other surgeon would do so either. -- Per interview of Staff G, (on-call surgeon) on 9/27/17 at 1:20 pm, he/she received a call from a nurse in the ED around 10:30 pm about a patient transfer request from Hospital A for surgical care of a large abscess. Staff G stated he/she felt the patient would be best treated at another facility. He/she anticipated being busy, as he/she normally is with ED calls, and it would be difficult to care for Patient #1. At the time of the call he did not have any patients to evaluate. Staff G indicated he/she was not aware of EMTALA obligations regarding recipient hospitals and has not received any EMTALA education. -- Review of Patient #2's "Regional Transfer Center Intake Form," indicated on 5/13/17 at 9:54 pm, Hospital B contacted UHS Wilson's Regional Transfer Center regarding the transfer of Patient #2 with an emergency medical condition (acute appendicitis, confirmed by imaging). The Transfer Center called Staff G (on-call surgeon) at 9:57 pm. Staff G called the Transfer Center back at 10:00 pm and refused the patient transfer. Documentation indicated Staff G stated he was the only surgeon available and he could not be taking call for 7 or more facilities. The form also had documentation regarding an email that was sent to Staff H (President of UHS Physician Group) and Staff I (Chief Medical Officer) for follow-up. -- Review of Patient #3's "Regional Transfer Center Intake Form," indicated on 4/29/17 at 12:25 pm Hospital A contacted UHS Wilson's Regional Transfer Center regarding the transfer of Patient #3 with an emergency medical condition (acute appendicitis, confirmed by imaging). The Transfer Center called Staff J (on-call surgeon) at 12:30 pm. Staff J called the Transfer Center back at 12:35 pm and refused the patient transfer. Documentation by the Transfer Center staff indicated, "Staff J declined, stated Hospital A is part of Hospital C and the patient can go there." -- Per interview of Staff H (President of UHS Medical Group) on 9/28/17 at 10:30 am, he/she is informed of transfer refusals and reviews cases when necessary with providers. Staff H spoke with the on-call surgeons involved with Patient #2 and Patient #3. They were informed of the need to accept patients. There was no formal documentation completed regarding the specific conversations with the providers. He/she explained unless it is unsafe, all patients should be accepted for transfer. He/she indicated EMTALA education is needed throughout the entire system of providers.

Based on findings from document review, medical record (MR) review, and interview, the facility failed to ensure that all patients received care that was consistent with prevailing standards of practice. Specifically an emergency department (ED) patient (Patient #1) identified as a risk to fall, fell and sustained injuries. Also 5 of 5 ED MRs (Patients #9, #6, #3, #10 and #4) lacked adequate documentation related to falls (i.e., fall risk assessment and/or fall prevention interventions.) Findings include: -- Review of the facility policy and procedure (P&P) titled "Fall Prevention Program/Patient Falls-ED Addendum," last revised 3/2014, directed ED nursing staff to perform a fall risk assessment on all patients presenting to the ED and document the findings in the triage nursing notes. All patients who are at risk for falling will be identified and the fall prevention plan should be implemented. The following actions should be implemented for all patients identified as at risk for falling: * A yellow "FALL RISK" wrist band will be applied to the patient * When possible place the patient in a room visible to the nurses station * One or two side rails up on stretcher * Bed in low position and brakes on * Call bell in reach and patient/family educated on it's use * Hourly monitoring by ED staff; one to one monitoring if necessary * Provide non-slip slippers * Staff remains with patient during toileting -- Per MR review, Patient #1, a [AGE]-year-old female, (MDS) dated [DATE] at 4:44 am with a chief complaint of prolapsed rectum and uterus. She was triaged at 4:55 am and nursing documentation revealed a history of dementia. A Fall Risk Assessment was completed which identified risk factors as the patient's age and history of falls. Interventions documented were, bed in low position, siderails up and call bell in reach. At 6:29 am nursing documentation revealed the patient was confused with dementia and incontinent of urine. At 7:15 am nursing documented the surgeon was at the bedside attempting prolapse repair and the patient was yelling out in pain. New physician orders were implemented. The patient was medicated with Fentanyl and Ativan. Nursing documented at 8:42 am that Patient #1 was calm and resting and vital signs were stable. Vital signs were repeated again at 9:01 am. The next documentation by nursing was at 9:20 am indicating the patient was found lying at the foot of the bed, face down in a large pool of blood, awake and moaning. Patient #1 was moved to a trauma room and later was admitted with a left eyebrow laceration, intracranial hemorrhage and left hip fracture. -- Per interview of Staff F, ED RN who provided care to Patient #1 on 9/13/17 at 8:42 am, Patient #1 came to the ED from a nursing home. She was complaining of pain due to her prolapsed rectum and uterus. Patient #1 was confused at times and was incontinent of urine. Staff F indicated he/she performed frequent bed checks. Her bed was in low position and side rails were up. Staff F could not recall if the yellow fall risk bracelet or non-slip slippers had been applied to the patient. When asked, he/she indicated a bed alarm was not placed under the patient. -- During interview of Staff A, ED RN who provided care to Patient #1 on 8/29/17 at 8:30 am and 9/13/17 at 9:00 am, he/she took report from the night nurse who had identified Patient #1 as a risk to fall. Staff A stated that he/she and the nurses aid were in the room frequently checking on Patient #1. The ED became very busy and 4 patients came in from a motor vehicle accident. At approximately 9:10 am Staff A looked in on Patient #1 and the patient was resting quietly in bed. At approximately 9:20 am, the nurses aid found Patient #1 on the floor. Staff A indicated he/she was not sure what fall interventions were implemented for Patient #1. Staff A could not recall if Patient #1 had a yellow fall risk bracelet or non-slip slippers on. When asked, Staff A indicated a bed alarm was not placed on the bed. Staff A stated that only the highest risk patients get a bed alarm. He/she stated the fall prevention P&P identifies which patients are classified as highest risk. -- Per interview of Staff H, Nursing Assistant on 9/14/17 at 1:00 pm, he/she spoke with Patient #1 and "she seemed a little confused but not bad." He/she does not remember if the yellow fall risk bracelet or non-slip slippers were in place. The patient was waiting for a surgeon to come and examine her. Staff H indicated she entered the room and found Patient #1 standing next to the bed and needing to go to the bathroom. Staff H assisted the patient back to bed and notified Staff A about the incident. The patient was then placed on the bedpan several times but was unable to urinate. The surgeon came to see the patient, but was unable to perform the procedure due to the patient's pain. Staff A gave Patient #1 pain medications and turned the lights off to help her rest. The next time he/she checked, Patient #1 was sleeping. A short time later when Staff H went to check the patient, she was found on the floor. Patient #1 was found standing next to the bed. No additional interventions were put in place to prevent a fall (for example, bed alarm, place closer to nurses station or one to one monitoring.) -- Per review of Patient #9's MR ([AGE] year-old male), he was triaged on 8/15/17 at 7:30 pm with a chief complaint of dizziness, weakness and near syncope. There was no documentation of a Fall Risk Assessment or fall prevention interventions implemented. -- Per review of Patient #6's MR ([AGE] year-old female), she was triaged on 8/28/17 at 8:17 am with a chief complaint of a fall. Nursing documentation at 8:40 am, under Fall Risk Assessment, indicated fall risk assessment completed. Risk factors identified included patient age greater than 65, history of fall and impairment of mobility. Fall intervention initiated, patient on stretcher, side rails up x 2, bed in low position, brakes on, call light in reach. Instructed patient to not get up without assistance. There was no documentation regarding fall bracelet or non-slip slippers. The same lack of adequate documentation related to falls was found in MRs for Patient #3, date of service - 8/1/17; Patient #10, date of service - 8/15/17; and Patient #4, date of service - 8/27/17. -- During interview of Staff G, ED Nurse Manager on 8/28/17 at 2:30 pm, he/she acknowledged the above findings.

Based on findings from document review, medical record (MR) review and interview, the facility did not ensure that all patients received care according to its policies and procedure (P&P) and current standards of practice related to vital sign monitoring for 1 of 11 patients, Patient #1. Findings include: -- The hospital P&P titled "Intravenous Thrombolytic Therapy for Acute Ischemic Stroke- TPA (tissue plasminogen activator)," last revised 2/2014, indicated that nursing staff should obtain initial vital signs (blood pressure (BP), pulse (P), respirations (R), oxygen saturation (O2 Sat) initially at the beginning of a TPA infusion and then at least every 15 minutes for 1 hour duration, then every 30 minutes for 6 hour duration and then hourly for 16 hours. -- Review of Patient #1's MR revealed that the patient presented to the emergency department (ED) on 2/27/16 with chief complaint of acute mental status change. At 20:36 (time of triage) vital signs were obtained: BP 167/76, P 77, R 22, O2 Sat 96 %. A hospital stroke response was activated. Patient A underwent diagnostic testing which included CT angiogram (CTA) Head which showed a large ischemic area in the left parietal lobe consistent with distal middle cerebral artery (MCA) occlusion. At 21:41, Staff A ordered Alteplase (TPA) 6.6 mg intravenously (IV) bolus once followed by 59.1 mg IV infusion over 1 hour. At 22:02 Staff B documented administration of Alteplase bolus (6.6 mg) and at 22:07, initiation of Alteplase 59.1 mg infusion over 1 hour. At 23:03, Patient #1's vital signs were: BP 145/73, P 72, R 16, O2 Sat 97%. Patient #1 remained in the ED until 00:30 on 2/28/16 and was then transported to the intensive care unit. There is no documentation in the MR indicating that Patient #1's vital signs were obtained every 15 minutes during the TPA infusion and every 30 minutes thereafter while in the ED, per hospital P&P. --During interview of Staff C on 5/5/16 at 14:30, the above finding was acknowledged.