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Based on a review of Maine Coast Memorial Hospital (MCMH), Emergency Department (ED) medical records, a review of policies and procedures, and interviews with key staff on August 5 to 7, 2014, it was determined that Maine Coast Memorial Hospital (MCMH), failed to provide the necessary stabilizing assessment and treatment to a patient seeking emergency medical care in the Emergency Department. These findings represented a violation of the Emergency Medical Treatment and Labor Act (EMTALA) and were determined to be an immediate jeopardy to the patients seeking emergency medical care at the hospital.

The evidence is as follows:

1. Maine Coast Memorial Hospital policy titled, 'Patient Rights and Responsibilities' stated, "....Every patient at MCMH has the right to: 1. Access to care and services..receive care, treatment, and services within the capacity and mission of MCMH.."

2. A review of MCMH policy titled, 'Emergency Room Transfer Policy' stated, "III. MEDICAL SCREENING REQUIREMENT..for any individual who comes to the Emergency Department and requests (or for whom a request is made) examination or treatment for a medical condition, MCMH shall provide an appropriate medical screening examination within its capabilities, including ancillary services routinely available to the hospitals top determine whether or not an emergency medical condition exists.....VI. NONDISCRIMINATION 1. MCMH shall not refuse to accept an appropriate transfer of an individual who requires specialized capabilities or facilities which MCMH has available."

3. A review of Patient A's medical record August 5-6, 2014, revealed that he/she arrived at the ED by ambulance on August 2, 2014. The medical record stated that the history of present illness was burning and cramping in the left calf. The record stated that the Emergency Medical Services (EMS) crew reported that they were transporting a bariatric patient with left leg pain and that he/she had requested transport to MCMH due to his/her Primary Care Physician being there. Upon EMS arrival at the hospital ambulance bay area, the ED charge nurse exited the ED and entered the ambulance with the patient and EMS crew still inside. The ED charge nurse informed the EMS crew and the patient that MCMH did not have weight appropriate equipment to keep the patient and staff safe. The Emergency Department Physician then went out to ambulance and spoke with the patient to discuss transfer to Eastern Maine Medical Center. The ED physician did not conduct any medical assessment or screening. The ED physician completed a form for the Emergency Medical Treatment and Labor Act (EMTALA) and the patient was taken by EMS to EMMC. The patient never exited the back of the ambulance, and no medical screening or assessment was conducted.

4. Patient A's Emergency Room Report stated that the patient was sent to the ED from a residential home for evaluation of left calf pain of roughly 24 hours duration. The report also indicated that the patient had a stated weight of greater than 600 to 700 pounds. The ED record by the physician stated. "PHYSICAL EXAMINATION: Not performed beyond my talking to the patient in the ambulance."

5. Additional medical records of Patient A's previous visits to the Emergency Department at Maine Coast Memorial Hospital were reviewed on August 5 and 6, 2014. The January 28, 2014, record revealed a four (4) day stay in the Emergency Department, and the surveyor noted that Patient A was seen and treated in the Emergency Department on February 10, 2014, and June 15, 2014 as well.

6. A telephone interview was conducted on August 4, 2014, at 2 p.m., with Patient A. He/She stated, "I had burning and cramping in my left calf since Friday and then on Saturday I still had it. ..I wanted to go to MCMH because I always go there.....The driver went into the Emergency department and was told to 'hold position'....a nurse came out and stated that it wasn't safe for me to be there. She said their equipment wouldn't hold me..the nurse made me feel very uncomfortable. She said she would get the supervisor and I said go ahead ...I was being polite but I was frustrated. They always take care of me there..[the doctor] came out and into the ambulance ..... he didn't check me out ...didn't take my vital signs and didn't look at my leg. He gave me his opinion that I would be in the Emergency Department at my own risk sitting in a wheelchair. He said the wheelchair was my only option and said it wasn't safe."

7. A tour was conducted in the Emergency Department on August 5, 2014, at approximately 9:00 a.m., the surveyor noted that there were seventeen (17) stretchers located in the Emergency Department. Twelve (12) of the stretchers were rated for 700 pounds. It was also observed that there was one (1) wheelchair in the hospital that had a weight capacity of 600 pounds. In an interview with the Charge Nurse on August 5, 2014 she confirmed that these same stretchers were in use on August 2, 2014

8. An interview was conducted on August 5, 2014, at 11:20 a.m., with the Emergency Department (ED) Charge Nurse who spoke with Patient A on August 2, 2014. The ED Charge Nurse stated that on August 2, 2014, EMS reported that Patient A had a weight of 600-700 pounds. The ED Charge Nurse stated, "The supervisor and I discussed this safety issue....I told [Patient A] that it would mean coming in at [Patient A's] own risk for safety ....I saw [Patient A] sitting on the foot of the stretcher at first and then standing in the ambulance...if the patient needed an ultrasound then [Patient A] would have to be on a stretcher ....my guess is that [Patient A] hadn't increased weight that much from the last time [Patient A] was here, but I went on what was stated as [Patient A's] weight ....I asked the patient and [Patient A] stated that the weight had not changed."

9. A telephone interview was conducted on August 5, 2014, at 11:30 a.m., with the physician who spoke to Patient A in the ambulance on August 2, 2014. He stated, "The nursing supervisor came to me and said the ED equipment was not rated for [Patient A] and I asked how we handled this in the past. I was lead to believe that the stretcher would not hold [Patient A]." When asked if he had considered moving the stretcher from the ambulance to the Emergency Department, he stated that he had considered it, but he felt that he could not conduct a thorough exam in that manner. The ED Physician stated, "I made the conscience decision and it was a hard call. Could I safely evaluate [Patient A]..no, could I adequately evaluate [Patient A]..no..I had the feeling that I couldn't. Seemed like the best thing to do was to transfer [Patient A]."

Based on document review, policy review, review of medical records and interviews with key staff on August 5 to 7, 2014, it was determined that the hospital failed to meet the emergency needs of patients by not providing necessary stabilizing treatment prior to transferring to another medical facility.

The evidence is as follows:

1. A review of Patient A's medical record August 5-6, 2014, revealed that he/she arrived at the ED by ambulance on August 2, 2014. The medical record stated that the history of present illness was burning and cramping in the left calf. The record stated that the Emergency Medical Services (EMS) crew reported that they were transporting a bariatric patient with left leg pain and that he/she had requested transport to MCMH due to his/her Primary Care Physician being there. Upon EMS arrival at the hospital ambulance bay area, the ED charge nurse exited the ED and entered the ambulance with the patient and EMS crew still inside. The ED charge nurse informed the EMS crew and the patient that MCMH did not have weight appropriate equipment to keep the patient and staff safe. The Emergency Department Physician then went out to ambulance and spoke with the patient to discuss transfer to Eastern Maine Medical Center. The ED physician did not conduct any medical assessment or screening, and did not order any treatments. The ED physician contacted Eastern Maine Medical Center (EMMC), and the patient was taken by EMS to EMMC. The patient never exited the back of the ambulance, and no medical screening or assessment was conducted while outside the MCMH Emergency Department.

2. Patient A's Emergency Room Report stated that the patient was sent to the ED from a residential home for evaluation of left calf pain of roughly 24 hours duration. The report also indicated that the patient had a stated weight of greater than 600 to 700 pounds. The ED record by the physician stated. "PHYSICAL EXAMINATION: Not performed beyond my talking to the patient in the ambulance." The surveyor noted that an adequate medical screening exam was not conducted and thus the need for stabilizing medical treatments could not be fully determined.

3. Additional medical records of Patient A's previous visits to the Emergency Department at Maine Coast Memorial Hospital were reviewed on August 5 and 6, 2014. The January 28, 2014, record revealed a four (4) day stay in the Emergency Department, and the surveyor noted that Patient A was seen and treated in the Emergency Department on February 10, 2014, and June 15, 2014 as well.

4. A telephone interview was conducted on August 4, 2014, at 2 p.m., with Patient A. He/She stated, "I had burning and cramping in my left calf since Friday and then on Saturday I still had it. ..I wanted to go to MCMH because I always go there.....The driver went into the Emergency department and was told to 'hold position'....a nurse came out and stated that it wasn't safe for me to be there. She said their equipment wouldn't hold me..the nurse made me feel very uncomfortable. She said she would get the supervisor and I said go ahead ...I was being polite but I was frustrated. They always take care of me there..[the doctor] came out and into the ambulance ..... he didn't check me out ...didn't take my vital signs and didn't look at my leg. He gave me his opinion that I would be in the Emergency Department at my own risk sitting in a wheelchair. He said the wheelchair was my only option and said it wasn't safe."

5. An interview was conducted on August 5, 2014, at 11:20 a.m., with the Emergency Department (ED) Charge Nurse who spoke with Patient A on August 2, 2014. The ED Charge Nurse stated that on August 2, 2014, EMS reported that Patient A had a weight of 600-700 pounds. The ED Charge Nurse stated, "The supervisor and I discussed this safety issue ....I told [Patient A] that it would mean coming in at [Patient A's] own risk for safety ....I saw [Patient A] sitting on the foot of the stretcher at first and then standing in the ambulance ...if the patient needed an ultrasound then [Patient A] would have to be on a stretcher ....my guess is that [Patient A] hadn't increased weight that much from the last time [Patient A] was here, but I went on what was stated as [Patient A's] weight ....I asked the patient and [Patient A] stated that the weight had not changed." There were no medical treatments ordered or provided to Patient A by MCMH staff.

6. A telephone interview was conducted on August 5, 2014, at 11:30 a.m., with the physician who spoke to Patient A in the ambulance on August 2, 2014. He stated, "The nursing supervisor came to me and said the ED equipment was not rated for [Patient A] and I asked how we handled this in the past. I was lead to believe that the stretcher would not hold [Patient A]." When asked if he had considered moving the stretcher from the ambulance to the Emergency Department, he stated that he had considered it, but he felt that he could not conduct a thorough exam in that manner. The ED Physician stated, "I made the conscience decision and it was a hard call. Could I safely evaluate [Patient A]..no, could I adequately evaluate [Patient A]..no..I had the feeling that I couldn't. Seemed like the best thing to do was to transfer [Patient A]."