Based on record review and interview, staff at this facility failed to report a suspected Emergency Medical Treatment and Labor Act (EMTALA) violation within the required 72 hours for 1 of 1 EMTALA complaint filed. Findings include: The facility policy titled, "EMTALA Violation Investigation and Reporting," dated December 11, 2017, was reviewed on 1/16/2019 at 8:37 AM. The policy revealed in part, "A receiving hospital that suspects it may have received an improperly transferred individual is required to promptly report the incident to the Centers for Medicare and Medicaid (CMS) or the appropriate State Agency (SA) within 72 hours of the occurrence." Per review of a complaint filed by Vice President A on 1/10/2019, the complaint alleges an inappropriate transfer occurred on 1/5/2019 for Patient #22. Per review of the emergency department log for January 2019 on 1/16/2019 at 11:30 AM, Patient #22 was transferred from an alternate acute care facility on 1/5/2019 with an acute myocardial infarction (heart attack). The reporting time frame exceeds the regulatory stipulation of 72 hours. Per interview with Vice President A on 1/1/6/2019 at 11:03 AM regarding if there were any other EMTALA violations in the past year that have not been reported within the 72 hour parameter, Vice President A said, "No."

Based on record review and interview, 1. Staff at this facility failed to report a suspected Emergency Medical Treatment and Labor Act (EMTALA) violation within the required 72 hours for 1 of 1 EMTALA complaint filed; 2. Staff failed to ensure that all areas where emergency patients are treated have EMTALA signs regarding their rights in 2 of 2 departments observed (Emergency Department, Maternal Health Department); and 3. Staff failed to accurately complete the patient transfer form information in 2 of 8 medical records reviewed of patients transferred to other facilities out of a total of 21 (Patient #15 and 20). Findings include: Facility staff failed to report a suspected EMTALA violation within 72 hours. See tag A2401. Facility staff failed to ensure all areas where emergency patients are treated have EMTALA signs. See tag A2402. Facility staff failed to complete transfer forms per the guidance on the form and/or facility policy. See tag A2409. The cumulative effect of these systematic failures has the potential to affect all emergency patients seeking care at this facility.

Based on observation and interview, staff failed to ensure that all areas where emergency patients are treated have Emergency Medical Treatment and Labor Act (EMTALA) signs regarding their rights posted in all areas emergency patients would be treated in 2 of 2 departments observed (Emergency Department, Maternal Health Department). Findings include: An observational tour of the emergency department was conducted on 1/16/2019 at 9:30 AM accompanied by Quality Coordinator C. The emergency department had 18 rooms, 6 were in use at the time of the tour and not observed. Of the remaining 12 rooms, room 4 did not have EMTALA signs. Per interview with Coordinator C on 1/16/2019 at 9:45 AM, Coordinator C stated, "No, no sign in here." An observational tour of the maternal health unit was conducted at 9:55 AM on 1/16/2019 accompanied by Director of Clinical Programs B and Charge Nurse F. There was no EMTALA signs at either entrance of the department by the elevators that patients with emergent maternal needs would use, and no EMTALA signs in room 16, the room Charge Nurse F indicated patients with an emergent maternal condition would be triaged in. On 1/16/2019 at 10:05 AM Charge Nurse F was conversing with housekeeping staff, who were cleaning room 16, about the EMTALA signs, and housekeeping staff stated, "We haven't had them since the remodeling." Per interview with Director B and Charge Nurse F on 1/16/2019 at 10:07 AM regarding when the remodeling took place, B and F both stated that it took place in phases, but started around November 2018.

Based on record review and interview, staff failed to accurately complete the patient transfer form information in 2 of 8 medical records reviewed of patients transferred to other facilities out of a total of 21 (Patient #15 and 20). Findings include: The facility policy titled, "Emergency Medical Screening, Treatment, & Transfer Policy (EMTALA)," which is not dated, was reviewed on 1/16/2019 at 8:48 AM. The policy revealed in part, "In the absence of a physician at the time of transfer, qualified medical personnel may sign the transfer certification, but only following consultation with a physician and determination by the physician that the transfer is appropriate. The physician must countersign the certification within 24 hours of the patient's transfer...In all cases of patient transfer, consent of the receiving hospital must be obtained and documented in the patient's medical record before the transfer." A review of Patient #20 medical record was conducted on 1/16/2019 at 12:20 PM accompanied by Quality Manager C who confirmed the following findings: Patient #20 was transferred to an alternate acute care facility on 1/7/2019. Patient #20 was seen and treated in the emergency room by a Physician Assistant, a Qualified Medical Personnel. In the section of the Physician Certification for Transfer form there was a signature of the Physician Assistant but not a physician countersignature for non-physician Qualified Medical Personnel. Per interview with Quality Manager C during the record review regarding physician signature, C stated,"The MD (medical doctor) signature should be there." A review of Patient #15's medical record was conducted on 1/16/19 at 12:35 PM accompanied by Quality Manager C who confirmed per interview the following findings: Patient #15 was transferred to an alternate acute care facility on 1/12/2019. There was no transfer form in the medical record. Per interview with Quality Manager C during the record review regarding the absence of a transfer form, C stated, "That should certainly be there." During an interview with the Emergency Department Manager E on 1/16/2019 at 12:35 PM, Manager E stated that there must be a transfer form, "It probably isn't scanned in yet." At end of survey (1:30 PM) on 1/16/2019 the form had not been located.

Based on record review and interview, the facility failed to ensure all patients transferred from another facility were accompanied with transfer forms, evidence of a medical screening exam and accepted by a facility physician, in 1 of 1 received transfer record reviewed. The effect of this deficiency potentially affect all patients transferred to the facility from another hospital for treatment. Findings include: The facility failed to ensure patients received from other hospitals were accepted and accompanied with evidence of a medical screening exam, transfer documents and physician to physician contact. See tag C2411.

The facility failed to ensure patients received from other hospitals were accepted and accompanied with evidence of a medical screening exam, transfer documents and physician to physician contact, in 1 of 1 received transferred patient record reviewed (1). This deficiency potentially affects all patients transferred from another facility without transfer documents for medical treatment. Findings include: Per review of Patient #1's obstetric triage and labor documentation, Patient #1 arrived at the facility on 2/19/17 at 12:31 AM, in labor accompanied by a midwife who believed the patient may have a breech presentation and needed a cesarean section. Per the Delivery Record, at 2:02 AM Patient #1 delivered an infant vaginally. The infant was not in breech position. The patient was triaged at 12:31 AM, delivered vaginally and discharged at 4:10 AM. This was confirmed in interview during record review with Quality Compliance Coordinator E on 2/27/17 at 9:30 AM. Per interview with Registered Nurse Legal Counsel B on 2/28/17 at 9:01 AM, s/he was made aware of Patient #1 arriving at the facility from another Eau Claire hospital on [DATE], and contacted the other hospital to confirm. Nurse B said after discussion with the other legal counsel they decided to report the inappropriate transfer, due to Patient #1 not having a Medical Screening Exam, proper transfer forms completed or physician to physician contact for acceptance. Per interview on 2/28/17 at 9:25 AM with Privacy Officer C, s/he provided a copy of an email she sent to a State Agency contact, on 2/22/17 at 2:46 PM, reporting the inappropriate transfer, and requested a "read receipt:" Officer C said s/he received a relayed receipt from Mail Delivery System <[email protected]> on 2/22/17 at 3:08 PM, that stated "Delivery to these recipients or groups is complete, but no delivery notification was sent by the destination server..." Officer C said s/he believed the email was received because the MAILER-DAEMON message said it was complete. Per Officer C, s/he never received a read receipt. Officer C was unaware that notifications from MAILER-DAEMON usually means it was not delivered. Review of the email sent on 2/22/17 by Privacy Officer C had an obsolete email address for the State Agency contact. Per email confirmation on 2/28/17 at 9:41 AM the intended recipient at the State Agency confirmed the email was not received.