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Based on staff interview and in the course of a complaint investigation, it was determined the facility staff failed to comply with the special responsibilities of Medicare hospitals in emergency cases. The facility staff failed to provide evidence of an appropriate medical screening examination for the patient named in the complaint.

The findings include:

As part of the complaint investigation, surveyors requested the Emergency Department (ED) Central Log. The ED Central Log contained no evidence the patient named in the complaint was seen in the ED between the dates of 12/15/10 through 1/24/11.

The EMT who transported the patient from the patient's home to the receiving facility on 1/7/11 was interviewed via phone on 1/26/11. The EMT stated that prior to transporting the patient to the receiving facility, the ambulance crew stopped at the ED of the facility named in this complaint. He stated when he arrived in the ED with the patient, an ED nurse informed him the patient was to be directly transported to a hospital with MRI (Magnetic Resonance Imaging) and neurosurgical capabilities (the receiving hospital). The EMT verified the facility named in this complaint never took over care of the patient and the ambulance crew continued the transport to the receiving hospital.

The facility failed to provide an appropriate medical screening examination prior to the patient leaving the ED.

Please refer to ?489.24(a) for additional information.

Based on Emergency Department (ED) central log review, staff interviews, policy and procedure review, and in the course of a complaint investigation, it was determined the facility staff failed to provide evidence of an appropriate medical screening examination (MSE) for the patient named in the complaint.

The findings include:

On 1/26/11 the complainant was interviewed via telephone and confirmed the alleged incident for the patient named in this complaint took place on 1/7/11. On 1/25/11, the facility named in this complaint provided their ED Central Log for review. The ED Central Log contained no evidence the patient was seen in the ED between the dates of 12/15/10 through 1/24/11, and therefore, no medical record was available for surveyor review.

The receiving hospital was located in a different state from the complaint investigation and therefore the surveyors were unable to review the patient's clinical record. Telephone interviews with staff at the receiving hospital took place on 1/26/11 to confirm the patient was received and admitted at that facility on 1/7/11.

The EMT (Emergency Medical Technician) who transported the patient named in the complaint on the date in question of 01/07/11 was identified. A copy of the EMT's transport note was reviewed. That note read, "After first stopping at (facility named in complaint) where they said they did not have neuro or MRI capabilities and proper equipment to evaluate the pt. (sic) He was transported to (name of receiving facility) ER due to the fact that it is the closest facility with neuro and diagnostic equipment needed to evaluate the patient." A review of the ambulance service daily call log for 1/7/11 revealed the call regarding the patient named in the complaint was dispatched as a non-emergent transport from the patient's home to the intended receiving hospital and had been requested by a private citizen. The EMT's note failed to document why the patient transport deviated from the original dispatch/plan.

A phone interview took place on 01/27/11 at 1:10 PM with the EMT who transported the patient on 1/7/11. The EMT confirmed he responded to the patient's home on 01/07/11. He stated his understanding was the patient had sustained a fall several days before, was seen in the local Emergency Room (ER) and released home where he continued to have some symptoms such as swelling of his hands and ankles and inability to ambulate. The EMT stated when he arrived at the patient's home, the family wanted the patient transported as a non-emergency to the hospital which is referred to in this report as the receiving hospital. The EMT stated he told the patient's wife he had to take the patient to the closest emergency room (ER). The EMT said he then transported the patient to the ER of the hospital named in the complaint. Upon arrival, the EMT took the patient via stretcher inside the ER, and was met just inside the doors by a male ER nurse who informed him that hospital did not have MRI (Magnetic Resonance Imaging) testing or neurosurgeon availability. The nurse told the EMT the patient was to be taken on to the intended/receiving hospital . The EMT stated it was his understanding the patient's physician, not the ER nurse, wanted the patient taken to a facility with appropriate available services. The EMT added the patient "was never taken off the rescue squad's stretcher and never turned over to their care." The ER nurse told the EMT he had been in touch with the ambulance's dispatch to avoid the unintended stop at this ER and to instruct the ambulance crew to directly transport the patient to the intended hospital. The EMT stated "that communication did not make it to the EMS squad" (EMS= Emergency Medical Services). The EMT stated the intended/receiving hospital is only about 30 minutes from the hospital named in the complaint therefore he felt it was the best decision for the patient medically and financially. The EMT further stated, "otherwise he would have had to be registered, evaluated, transferred and he would have had 2 ambulance charges and 2 different hospital charges." However, the EMT was unable to explain why the transport deviated from the original plan which was for a non-emergent transport directly to the hospital with appropriate capabilities.

The nurse who spoke to the EMT at the facility named in the complaint was identified. A phone interview with this nurse took place on 1/27/11. He stated he received a phone call from a Physician's Assistant (PA) on 1/7/11 concerning a patient the PA wanted to have an MRI and he confirmed to the PA that his facility did not have MRI capability at that time. The PA called the ED nurse later and said she had arranged an ambulance to transport the patient from his home to a facility with MRI capability but was concerned the ambulance service may stop at the facility named in this complaint instead of continuing to the receiving facility. She reiterated the patient needed an MRI and therefore needed the specialized services of the originally intended hospital. The ED nurse then called the ambulance service dispatch to clarify the patient was to be transported to the hospital the PA had originally requested due to their MRI capability. The nurse stated that despite communication with the ambulance dispatch, the ambulance arrived at his ED's door with the patient on a stretcher and he told them they were supposed to have taken the patient to another facility. A physician who works with the PA was contacted by the ED nurse. That physician told the nurse he wanted the patient to go to the receiving facility where he could get an MRI and where there was neurosurgery available. The nurse relayed the physician's comments to the ambulance crew. The patient had been brought into the ED's bay, had not been put into a room and remained on the ambulance stretcher. The nurse also recalled the patient's wife asking where the PA wanted the patient to go. The nurse acknowledged he never saw the patient and did not recall discussing the situation with the ED physician working that day. The nurse stated he understood this patient was a non-emergent care transport. Approximately one hour later, the nurse notified the PA that the patient had been transported to the intended facility.

The PA was interviewed via phone on 1/27/11. She clarified that although she is not this patient's health care provider, the patient is her great-uncle and his wife called her for advice since the patient's primary care physician was out of the country. On 1/7/11, the patient's wife relayed the patient's recent history to the PA. The history included that the patient had fallen on 1/2/11 or 1/3/11 and could not use his arms or legs. An ambulance had taken the patient to a local hospital's ED on 1/3/11 where the patient was seen and discharged home the same day after having neuro checks, a CT Scan and told he had not had a stroke. The PA stated the patient had been discharged from the ED still unable to walk and required ambulance transport back home. The PA spoke with the patient via phone who told her he had slipped on ice while attempting to get on his four-wheeler. He said he had hit his back and buttocks, that he had not hit his head and he had laid there for four hours without help. The patient told the PA he had not voided or defecated since his fall, that his lower legs and feet were swollen with one turning black and that his wife was holding the phone receiver to his ear since he could not move his arms.

The PA told the surveyors that she then talked with a physician where she works and he agreed the patient needed to be seen by a neurosurgeon as soon as possible. The PA called a local ambulance service to request they transport the patient as a non-emergency to the receiving hospital where he could undergo an MRI and a neurosurgery evaluation. The ambulance service agreed. After the ambulance service arrived at the patient's home, the patient's wife called the PA and said the EMS workers were transporting the patient to the facility named in this complaint since it was closer than the intended facility. The PA then called the facility named in this complaint and was told by the ED nurse they had no MRI services. She told the nurse the patient needed to go to the receiving hospital for both an MRI and neurosurgery evaluation. The PA verified the only person she spoke with at the facility named in this complaint was the ED nurse. The PA stated that she placed a second call to the ambulance service to ensure the patient would be transported directly to the intended facility.

The PA informed the surveyors the patient is currently in a nursing care facility after spending approximately one week at the receiving facility. He continued to be paralyzed from the neck down and was awaiting surgery after the swelling subsides. The PA acknowledged she had not seen the patient's MRI results but the his wife told her there was compression to the spinal cord. The PA added that the patient was found to be in acute renal failure as well.

On 1/26/11, the receiving facility's ED charge nurse was interviewed via phone due to that facility being located in another state. The ED charge nurse verified the facility is a Level 2 Trauma Center with MRI capabilities 24 hrs/day and frequently received area transfers/transports for specialty services such as neurological evaluations. The charge nurse verified the patient was received via ambulance on 1/7/11 with the chief complaint being an inability to ambulate times five days. He stated the patient was admitted to the hospital from their ED with diagnoses of acute renal failure, thrombocytopenia, cervical strain (fall) and weakness. The patient received a CT Scan in the ED. An MRI of the lumbar and cervical regions was completed on 1/9/11 which showed "compression."

A face-to-face interview of the ED nurse manager from the facility named in this complaint was conducted on 1/25/11. Although she was not working on the afternoon of 1/7/11 she stated that generally EMS makes the decision where to transport patients when they respond to a call. She said that once a patient comes through the ED doors, the expectation is that the patient is there for treatment. The ED staff takes report from the EMS and once the patient has been transferred to the hospital's bed, the patient is then the ED's responsibility.

The ED's policy and procedures were reviewed on 1/25/11. The policy titled, "Emergency Medical Treatment and Patient Transfer" read in part that a Medical Screening would be performed "when an individual comes to the Emergency Department of the Hospital ... and a request is made on the individual's behalf for a medical examination or treatment, an appropriate medical screening examination, within the capabilities of the department, shall be provided to determine whether an emergency medical condition exists..."