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Based on review of hospital policy, dedicated emergency department (DED) log, closed medical record review, EMS staff, hospital staff and physician interviews the facility failed to ensure compliance with 42 CFR 489.24.

The findings included:

1. The hospital failed to ensure an appropriate medical screening examination was completed for 1 of 21 sampled patients (Patient #21) with an emergency medical condition that presented to the hospital's dedicated emergency department (DED).

~cross refer to 489.24(r)(c) Medical Screening Exam - Tag A2406

2. The hospital failed to provide stabilizing treatment within its capability and capacity for 1 of 21 sampled patients (Patient #21) that presented to the hospital's dedicated emergency department with an emergency medical condition.

~ cross refer to 489.24(d) (1-3) Stabilizing Treatment- Tag A2407

3. The hospital's dedicated emergency department (DED) failed to ensure an appropriate transfer by failing to ensure physician certification that the medical benefits expected at the time of transfer outweighed the risks of transfer, failing to ensure the receiving facility had accepted the transfer and failing to send related medical records to the receiving facility for 1 of 6 patients transferred with an emergency medical condition (Patient #21).

~ cross refer to 489.24(e)(3) Appropriate Transfer - Tag A2409

Based on review of hospital policy, ambulance trip report, dedicated emergency department (DED) log and staff interviews, the hospital failed to ensure that each individual presenting to the DED seeking care for an emergency medical condition was included on the central DED log for 1 of 21 DED patients reviewed (Patient #21).

The findings include:

Review of the hospital's "EMTALA Policy" revised 02/2012 revealed "...Emergency Department Patient Medical Screening Purpose To define the process and requirements for medical screening of individuals 'coming to the Emergency Department' as defined under EMTALA. ...Scope An individual is considered to have 'come to the Emergency Department' if the individual is not an Existing Patient and: 1. The individual has presented at a Dedicated Emergency Department and requests examination or treatment for a medical condition, or has such a request made on his or her behalf. ...3. The individual is in a ground or air ambulance on Hospital Property. ...3. All individuals coming to the Emergency Department shall be logged in. ...".

Review of an ambulance trip report from (local) County EMS confirmed that Patient #21 was taken to Hospital A's (receiving hospital) DED on 12/09/2013. Review of the trip report recorded the ambulance crew arrived at Hospital A (receiving hospital) at 0748. Review of the report revealed, "...Once we arrived at ER nurse came out and advised us the CT (computerized tomography) was down...took pt to (Hospital B [Receiving Hospital]) ER ...". Review of the report revealed EMS arrived at Hospital B at 0817.

Interview on 12/16/2013 at 1330 with RN (Registered Nurse) #1 revealed the nurse was staffing Hospital A's DED on 12/09/2013. Interview revealed, "we received a phone call from EMS about 0730. They said they had an 82 year-old male having a possible stroke. He had left-sided weakness. I told them we would give a bed assignment on arrival. The EMS truck showed up at the back door about 7:35. I went to the back door, the ambulance entrance. The EMS driver got out. I told him not to bring the patient inside because our CT scanner was out and we were trying to figure out whether to take the patient somewhere else. I stood out there with them while (RN #2- charge nurse) talked to the house supervisor. They decided the patient needed to go somewhere else".

Review of Hospital A's DED log on 12/16/2013 revealed no evidence Patient #21 had presented to the hospital's DED on 12/09/2013. Interview with administrative staff confirmed there was no medical record for Patient #21 for 12/09/2013.

Interview on 12/16/2013 at 1045 with administrative staff confirmed Patient #21 presented to the DED on 12/09/2013 via ambulance. Interview confirmed that Patient #21 was not on the DED log. Interview confirmed the hospital's EMTALA policy was not followed.

Based on review of hospital policy, ambulance trip report, dedicated emergency department (DED) log and EMS staff, hospital staff and physician interviews, the hospital failed to ensure an appropriate medical screening examination was completed for 1 of 21 sampled patients (Patient #21) with an emergency medical condition that presented to the hospital's dedicated emergency department (DED).

The findings include:

Review of the hospital's policy, "EMTALA Policy", revised 02/2012, revealed, "(Hospital A) is committed to complying with the Emergency Medical Treatment and Active Labor Act...EMTALA requires that a hospital with an emergency department provide to any individual who is not a patient of the hospital and who 'comes to the emergency department' an appropriate medical screening evaluation within the capability of the hospital's emergency department to determine whether an Emergency Medical Condition exists, regardless of the individual's ability to pay...Scope An individual is considered to have 'come to the Emergency Department' if the individual is not an Existing Patient and: ...3. The individual is in a ground or air ambulance on Hospital Property. ... Nursing Procedures... 4. No patient coming to the Emergency Department shall be denied Triage or Medical Screening Examination by an employee or medical staff member of this hospital...5. All patients will be offered a Medical Screening Examination based upon their priority as determined by: a. the Triage Nurse, b. other Registered Nurse in the absence of the Triage Nurse; c. priority determination of a Qualified Medical Person. ...Qualified Medical Personnel Procedures 1. A Qualified Medical Person shall provide a Medical Screening Examination to all patients who come to the Emergency Department. ...4. The Qualified Medical Person providing the Medical Screening Examination shall examine the patient, and where necessary to rule out any potential Emergency Medical Condition in the range of the differential diagnosis for the patient, shall order such testing and further examination...".

Review of an ambulance trip report, dated 12/09/2013, revealed Patient #21, an 80 year-old male, was transported from his residence to Hospital A's DED, with arrival time at Hospital A recorded as 0748. Review revealed, "80 y/o (year old) male pt (patient) went to bed around 10 pm last night and woke up this morning unable to move left side. Pt has history of CVA (cerebral vascular accident) 10 years ago but recovered almost 90% per family members. Today pt is not able to move upper or lower left extremities. Pt is alert but gazing to the right. Pt will respond to following your finger but drifts back to gazing to right as soon as he stops. Pt talks a little garbled but makes since in everything he says. He is able to give personal information and date of current day. V/S (vital signs) taken, accucheck (blood sugar) 89 (normal). 12 lead monitor. Pt was placed on 2 L (liters) 02 (oxygen). Prepared to load. Enroute ER (emergency room) contacted by phone for possible stroke alert. Unsure of onset of S/S (signs and symptoms) due to last time pt was scene (sic) was last night around 10 pm and was fine at that time. Plus pt has history of CVA. Enroute IV (intravenous) started, recheck V/S (extremely hard due to Parkinson's). Once we arrived at ER, nurse came out and advised us that CT (computerized tomography) was down. Pt was given Zofran (anti-nausea) 4 mg (milligrams) IV and Medic 7 took patient to (Hospital B) ER. ...". Review revealed the ambulance departed Hospital A's DED at 0751 and arrived at Hospital B's DED at 0817.

Interview on 12/17/2013 at 0915 with Paramedic #1 revealed the county's EMS (emergency medical services) was dispatched to Patient #21's residence on 12/09/2013 at 0707, with arrival at 0714. Interview revealed, "when we got there, he was laying in the bed. His family member said he had garbled speech and a history of left sided weakness from a previous stroke but that he had recovered 90%. The night before he had been walking around. His relatives said he couldn't get out of bed to use the bathroom. He was incontinent prior to our arrival. His blood pressure was 134/80, oxygen saturation was 96%, heart rate was 100 and respirations were 16. He was doing nothing with his left side. We left his residence around 7:34 and arrived at the EMS dock (Hospital A) at 7:43. I was in the back with the patient. (EMT #1- EMS Driver) called (Hospital A) enroute and told them we had a possible stroke alert. He told them the symptoms and history. Nobody said anything about not bringing him here (Hospital A). My partner said, 'I've got a nurse on the ramp'. I heard someone on the radio say, 'contact us regarding CT being down'. (EMT #1) got out of the truck and the nurse told him the CT was down. They told us to wait a minute. I became concerned that it was taking too long. I stepped out of the truck and asked what was going on. The nurse said, 'our CT is down and we can't do anything for him'. She said, 'wait and let me be sure'. A few minutes passed. (EMT #1) came back and said, 'let's go to (Hospital B). I gave him Zofran per EMS protocol so he wouldn't get nauseated from riding backwards in the truck. We left about 7:51 and arrived there at 8:17. We went lights and sirens. We needed to get there fast". Interview confirmed Patient #21 was not seen by a nurse or physician at Hospital A. Interview confirmed Patient #21 was not offered a medical screening examination at Hospital A.

Telephone interview on 12/17/2013 at 1310 with EMT #2 (Emergency Medical Technician) revealed he was the driver of the ambulance that transported Patient #21 to Hospital A's DED on 12/09/2013. Interview revealed, "I called (Hospital A's) ED and told them (Patient #21's) symptoms. They never said not to come. I was met at the truck before I could get out. The nurse said, 'Hold on just a second. I need to see if the CT scan is still down. I followed her in the ED. A nurse told me to take the patient to (Hospital B). We left and it took us about 30 minutes to get there. We went emergency, lights and sirens". Interview confirmed Patient #21 was not seen by a nurse or physician at Hospital A. Interview confirmed Patient #21 was not offered a medical screening examination at Hospital A.

Review of Hospital A's DED log on 12/16/2013 revealed no evidence Patient #21 had presented to the hospital's DED on 12/09/2013. Interview with administrative staff confirmed there was no medical record for Patient #21 for 12/09/2013.

Interview on 12/16/2013 at 1330 with a registered nurse (RN #1) revealed the nurse was working as a staff nurse in Hospital A's DED on 12/09/2013. Interview revealed RN #1 did not have any assigned patients in the DED at 0730 on 12/09/2013. Interview revealed, "I got a phone call from EMS saying they had an 82 year old male having a possible stroke. They told me his vital signs and nothing jumped out as abnormal. I told them I would give a bed assignment on arrival. They called because our radios were down. I got off the phone with them and discussed with (RN #2) which room to put him in. About one minute into our conversation, we remembered the CT scanner was down. The EMS truck showed up at our ambulance entrance about 7:35. I went out and told the driver not to get the patient out because our CT scanner was down and we were trying to figure out whether they needed to take the patient somewhere else. I stood out there while (RN #2) talked to the house supervisor. They decided the patient needed to go somewhere else. They suggested they go to (Hospital B). I did not call (Hospital B)". Interview revealed, "I never went to the back of the EMS truck to see the patient (Patient #21)". Interview further revealed, "(Physician A) heard us talking and he didn't tell us to bring the patient in". Interview confirmed Patient #21 was not medically screened at Hospital A. Interview confirmed Patient #21 had an emergency medical condition when he presented to Hospital A. Interview confirmed the hospital's EMTALA policy was not followed.

Interview on 12/16/2013 at 1410 with RN #2 revealed the nurse was the charge nurse for Hospital A's DED on 12/09/2013 beginning at 0700. Interview revealed, "we got a call from EMS that they had a male with left sided paralysis who was normal the night before. I paged CT and the nursing supervisor to find out the status of the scanner. I told the supervisor the truck (EMS) was on its way. During that time, the truck pulled up at the back door. We couldn't decide what to do. The patient needed what we didn't have. I told (RN #1) to tell the truck to hang on just a minute. I asked the driver was he (Patient #21) stable and he said 'yes'. I said, 'can he make it to (Hospital B)'. He said, 'yes'. I told him to take him (Patient #21) to (Hospital B)". Interview revealed RN #2 did not communicate with the DED physician that Patient #21 was at the ambulance entrance with a possible stroke. Interview revealed Hospital A had available beds in the DED when Patient #21 presented via EMS. Interview revealed, "it was my decision to send him to (Hospital B)". Interview confirmed Patient #21 was not medically screened at Hospital A. Interview confirmed Patient #21 had an emergency medical condition when he presented to Hospital A. Interview confirmed the hospital's EMTALA policy was not followed.

Interview on 12/16/2013 at 1355 with RN #3 revealed the nurse was the house supervisor at Hospital A on 12/09/2013. Interview revealed, "I knew the CT scanner had been down since the afternoon before (12/08/2013). (RN #2) called me about (Patient #21) at the back door of the ER on the EMS truck. I went over with her that if the patient had a bleed, we didn't have a CT scanner so we couldn't treat him". Interview confirmed Patient #21 was not medically screened at Hospital A. Interview confirmed Patient #21 had an emergency medical condition when he presented to Hospital A. Interview confirmed the hospital's EMTALA policy was not followed.

Interview on 12/16/2013 at 1440 with Physician A revealed the physician was working in Hospital A's DED on 12/09/2013 beginning at 0700. Interview revealed, "I overheard that a male patient was coming in with a possible stroke. I was not made aware that he was at the EMS dock". Interview further revealed, "I did not go out to see the patient (Patient #21)". Interview confirmed Patient #21 was not medically screened at Hospital A. Interview confirmed Patient #21 had an emergency medical condition when he presented to Hospital A. Interview confirmed the hospital's EMTALA policy was not followed.

Telephone interview on 12/17/2013 at 1105 with Physician B revealed the physician is the medical director for Hospital A's DED. Interview revealed, "I was not made aware of this incident until yesterday. Any patient within 250 feet of our property must be seen by a provider prior to discharge. It is our obligation to evaluate and stabilize a patient prior to discharge. We should have seen this patient (Patient #21). We didn't follow the law".

Based on hospital policy and procedure review, EMS (Emergency Medical Services) trip report, closed medical record review,and EMS staff, hospital staff and physician interviews, the hospital staff failed to provide stabilizing treatment within its capability and capacity for 1 of 21 sampled patients (Patient #21) that presented to the hospital's dedicated emergency department with an emergency medical condition.

The findings include:

Review of the hospital's policy, "EMTALA Policy", revised 02/2012, revealed, "(Hospital A) is committed to complying with the Emergency Medical Treatment and Active Labor Act...EMTALA requires that a hospital with an emergency department provide to any individual who is not a patient of the hospital and who 'comes to the emergency department' an appropriate medical screening evaluation within the capability of the hospital's emergency department to determine whether an Emergency Medical Condition exists, regardless of the individual's ability to pay. If an Emergency Medical Condition is determined to exists, the hospital must provide any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital...Scope An individual is considered to have 'come to the Emergency Department' if the individual is not an Existing Patient and: ...3. The individual is in a ground or air ambulance on Hospital Property. ...Qualified Medical Personnel Procedures ...5. If an Emergency Medical Condition is detected, Necessary Stabilizing Treatment to Stabilize a patient's Emergency Medical Condition shall be rendered in the hospital... Stabilize With respect to an Emergency Medical Condition, to provide whatever treatment of the condition is necessary to assure, within reasonable medical probability, that no material deterioration is like to result from [or occur during] the Transfer...".

Review of an ambulance trip report, dated 12/09/2013, revealed Patient #21, an 80 year-old male, was transported from his residence to Hospital A's DED, with arrival time at Hospital A recorded as 0748. Review revealed, "80 y/o (year old) male pt (patient) went to bed around 10 pm last night and woke up this morning unable to move left side. Pt has history of CVA (cerebral vascular accident) 10 years ago but recovered almost 90% per family members. Today pt is not able to move upper or lower left extremities. Pt is alert but gazing to the right. Pt will respond to following your finger but drifts back to gazing to right as soon as he stops. Pt talks a little garbled but makes since in everything he says. He is able to give personal information and date of current day. V/S (vital signs) taken, accucheck (blood sugar) 89 (normal). 12 lead monitor. Pt was placed on 2 L (liters) 02 (oxygen). Prepared to load. Enroute ER (emergency room) contacted by phone for possible stroke alert. Unsure of onset of S/S (signs and symptoms) due to last time pt was scene (sic) was last night around 10 pm and was fine at that time. Plus pt has history of CVA. Enroute IV (intravenous) started, recheck V/S (extremely hard due to Parkinson's). Once we arrived at ER, nurse came out and advised us that CT (computerized tomography) was down. Pt was given Zofran 4 mg (milligrams) IV and Medic 7 took patient to (Hospital B) ER. ...". Review revealed the ambulance departed Hospital A's DED at 0751 and arrived at Hospital B's DED at 0817.

Review of Hospital A's DED log on 12/16/2013 revealed no evidence Patient #21 had presented to the hospital's DED on 12/09/2013. Interview with administrative staff confirmed there was no medical record for Patient #21 for 12/09/2013.

Closed medical record review of Patient #21 from Hospital B revealed the patient arrived at Hospital B's DED on 12/09/2013 at 0824 and was triaged immediately. Documented vital signs on arrival were: Blood Pressure 154/63, pulse 109, respirations 20, oxygen saturation 97% and temperature 98.6 degrees Fahrenheit orally. Documented chief complaint was left sided weakness, patient unable to move left side with a previous history of CVA (cerebrovascular accident) to left side and regained 90% of use. Further documentation revealed the patient was incontinent of urine, was alert and verbally responsive. Further record review revealed Patient #21 was medically screened by Hospital B's DED physician at 0829. Documentation by the physician at 0859 revealed the patient's left arm and leg was rigid and the patient was unable to move with no sensation on the left. Further record review revealed a CT of the head without contrast was ordered and resulted as nothing acute. Review revealed an EKG was performed and interpreted as atrial fibrillation. Further review revealed the DED physician's diagnosis was cerebral vascular accident and Patient #21 was admitted to Hospital B for further treatment. Review of the dictated history and physical examination for Patient #21 revealed, "...past medical history significant for atrial fibrillation status post pacemaker, not on Coumadin secondary to falls, hypertension, parkinsonism, and previous CVA who presented to the ER for evaluation of left-sided weakness ...Impression: 1. Acute ischemic cerebrovascular accident. He has left-sided hemiplegia (paralysis) ... " . Further review revealed the patient was admitted to a telemetry -monitored bed and was discharged to the VA (Veterans Hospital) on 12/09/2013 for rehabilitation. Review of the physician's dictated discharge summary, dated 12/12/2013, revealed, "...Significant procedures during the hospitalization: 1. A chest x-ray on admission showed a pacemaker device in place, arthritic changes, and nothing acute. 2. A head CT on admission showed microvascular changes and atrophy with no definite abnormalities identified. 3. A carotid ultrasound showed less than 50% stenosis at the origin of the right ICA, and no hemodynamically significant stenosis was found. ...5. An EKG showed atrial fibrillation at 89. There was some evidence of ventricular pacing and nonspecific changes. ...Hospital Course: ...The patient had left hemiplegia and was having difficulty talking and appeared to have symptoms consistent with a CVA. His head CT did not show any evidence of bleeding. ...He will require aggressive inpatient rehab and he wished to go through the VA medical system for this ....At this point, he is medically stable for transfer ...".

Interview on 12/17/2013 at 0915 with Paramedic #1 revealed the county's EMS (emergency medical services) was dispatched to Patient #21's residence on 12/09/2013 at 0707, with arrival at 0714. Interview revealed, "when we got there, he was laying in the bed. His family member said he had garbled speech and a history of left sided weakness from a previous stroke but that he had recovered 90%. The night before he had been walking around. His relatives said he couldn't get out of bed to use the bathroom. He was incontinent prior to our arrival. His blood pressure was 134/80, oxygen saturation was 96%, heart rate was 100 and respirations were 16. He was doing nothing with his left side. We left his residence around 7:34 and arrived at the EMS dock (Hospital A) at 7:43. I was in the back with the patient. (EMT #1- EMS Driver) called (Hospital A) enroute and told them we had a possible stroke alert. He told them the symptoms and history. Nobody said anything about not bringing him here (Hospital A). My partner said, 'I've got a nurse on the ramp'. I heard someone on the radio say, 'contact us regarding CT being down'. (EMT #1) got out of the truck and the nurse told him the CT was down. They told us to wait a minute. I became concerned that it was taking too long. I stepped out of the truck and asked what was going on. The nurse said, 'our CT is down and we can't do anything for him'. She said, 'wait and let me be sure'. A few minutes passed. (EMT #1) came back and said, 'let's go to (Hospital B). We left about 7:51 and arrived there at 8:17. I gave him Zofran per EMS protocol so he wouldn't get nauseated from riding backwards in the truck. We went lights and sirens. We needed to get there fast". Interview confirmed Patient #21 was not seen by a nurse or physician at Hospital A. Interview confirmed Patient #21 was not offered stabilizing treatment at Hospital A.

Telephone interview on 12/17/2013 at 1310 with EMT #2 (Emergency Medical Technician) revealed he was the driver of the ambulance that transported Patient #21 to Hospital A's DED on 12/09/2013. Interview revealed, "I called (Hospital A's) ED and told them (Patient #21's) symptoms. They never said not to come. I was met at the truck before I could get out. The nurse said, 'Hold on just a second. I need to see if the CT scan is still down. I followed her in the ED. A nurse told me to take the patient to (Hospital B). We left and it took us about 30 minutes to get there. We went emergency, lights and sirens". Interview confirmed Patient #21 was not seen by a nurse or physician at Hospital A. Interview confirmed Patient #21 was not offered stabilizing treatment at Hospital A.

Interview on 12/16/2013 at 1330 with a registered nurse (RN #1) revealed the nurse was working as a staff nurse in Hospital A's DED on 12/09/2013. Interview revealed RN #1 did not have any assigned patients in the DED at 0730 on 12/09/2013. Interview revealed, "I got a phone call from EMS saying they had an 82 year old male having a possible stroke. They told me his vital signs and nothing jumped out as abnormal. I told them I would give a bed assignment on arrival. They called because our radios were down. I got off the phone with them and discussed with (RN #2) which room to put him in. About one minute into our conversation, we remembered the CT scanner was down. The EMS truck showed up at our ambulance entrance about 7:35. I went out and told the driver not to get the patient out because our CT scanner was down and we were trying to figure out whether they needed to take the patient somewhere else. I stood out there while (RN #2) talked to the house supervisor. They decided the patient needed to go somewhere else. They suggested they go to (Hospital B). I did not call (Hospital B)". Interview revealed, "I never went to the back of the EMS truck to see the patient (Patient #21)". Interview further revealed, "(Physician A) heard us talking and he didn't tell us to bring the patient in". Interview confirmed Patient #21 was not provided stabilizing treatment at Hospital A. Interview confirmed Patient #21 had an emergency medical condition when he presented to Hospital A. Interview confirmed the hospital's EMTALA policy was not followed.

Interview on 12/16/2013 at 1410 with RN #2 revealed the nurse was the charge nurse for Hospital A's DED on 12/09/2013 beginning at 0700. Interview revealed, "we got a call from EMS that they had a male with left sided paralysis who was normal the night before. I paged CT and the nursing supervisor to find out the status of the scanner. I told the supervisor the truck (EMS) was on its way. During that time, the truck pulled up at the back door. We couldn't decide what to do. The patient needed what we didn't have. I told (RN #1) to tell the truck to hang on just a minute. I asked the driver was he (Patient #21) stable and he said 'yes'. I said, 'can he make it to (Hospital B)'. He said, 'yes'. I told him to take him (Patient #21) to (Hospital B)". Interview revealed RN #2 did not communicate with the DED physician that Patient #21 was at the ambulance entrance with a possible stroke. Interview revealed Hospital A had available beds in the DED when Patient #21 presented via EMS. Interview revealed, "it was my decision to send him to (Hospital B)". Interview confirmed Patient #21 was not provided stabilizing treatment at Hospital A. Interview confirmed Patient #21 had an emergency medical condition when he presented to Hospital A. Interview confirmed the hospital's EMTALA policy was not followed.

Interview on 12/16/2013 at 1355 with RN #3 revealed the nurse was the house supervisor at Hospital A on 12/09/2013. Interview revealed, "I knew the CT scanner had been down since the afternoon before (12/08/2013). (RN #2) called me about (Patient #21) at the back door of the ER on the EMS truck. I went over with her that if the patient had a bleed, we didn't have a CT scanner so we couldn't treat him". Interview confirmed Patient #21 was not provided stabilizing treatment at Hospital A. Interview confirmed Patient #21 had an emergency medical condition when he presented to Hospital A. Interview confirmed the hospital's EMTALA policy was not followed.

Interview on 12/16/2013 at 1440 with Physician A revealed the physician was working in Hospital A's DED on 12/09/2013 beginning at 0700. Interview revealed, "I overheard that a male patient was coming in with a possible stroke. I was not made aware that he was at the EMS dock". Interview further revealed, "I did not go out to see the patient (Patient #21)". Interview confirmed Patient #21 was not provided stabilizing treatment at Hospital A. Interview confirmed Patient #21 had an emergency medical condition when he presented to Hospital A. Interview confirmed the hospital's EMTALA policy was not followed.

Telephone interview on 12/17/2013 at 1105 with Physician B revealed the physician is the medical director for Hospital A's DED. Interview revealed, "I was not made aware of this incident until yesterday. Any patient within 250 feet of our property must be seen by a provider prior to discharge. It is our obligation to evaluate and stabilize a patient prior to discharge. We should have seen this patient (Patient #21). We didn't follow the law".

Based on review of hospital policy, ambulance trip report, closed medical record review, dedicated emergency department (DED) log, and EMS staff, hospital staff and physician interviews, the hospital's dedicated emergency department (DED) failed to ensure an appropriate transfer by failing to ensure physician certification that the medical benefits expected at the time of transfer outweighed the risks of transfer, failing to ensure the receiving facility had accepted the transfer and failing to send related medical records to the receiving facility for 1 of 6 patients transferred with an emergency medical condition (Patient #21).

The findings include:

Review of the hospital's policy, "EMTALA Policy", revised 02/2012, revealed, "(Hospital A) is committed to complying with the Emergency Medical Treatment and Active Labor Act...If an Emergency Medical Condition is determined to exists, the hospital must provide any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or an appropriate transfer...Scope An individual is considered to have 'come to the Emergency Department' if the individual is not an Existing Patient and: ...3. The individual is in a ground or air ambulance on Hospital Property. ...Qualified Medical Personnel Procedures ...5. If an Emergency Medical Condition is detected, Necessary Stabilizing Treatment to Stabilize a patient's Emergency Medical Condition shall be rendered in the hospital or an Appropriate Transfer shall be initiated... Transfer The movement of the patient, for any reason- including discharge - from the premises of the hospital... For purposes of this hospital's EMTALA policies and procedures, an "Appropriate Transfer" to another facility for care of a patient with an Emergency Medical Condition that has not been Stabilized can only be initiated in specific situations described in the Transfer Policy. Even then, the Transfer is appropriate only if it includes the following elements: A. the Transferring hospital provides the medical treatment within its Capacity to minimize the risks to the individual's health...B. the receiving facility: i. has available space and qualified personnel for the treatment of the individual, and ii. has agreed to accept Transfer of the individual and to provide appropriate medical treatment; C. the Transferring hospital sends to the receiving facility all medical records...".

Interview on 12/17/2013 at 1350 with administrative staff revealed, "we do not have a specific transfer policy. We only follow our EMTALA policy".

Review of an ambulance trip report, dated 12/09/2013, revealed Patient #21, an 80 year-old male, was transported from his residence to Hospital A's DED, with arrival time at Hospital A recorded as 0748. Review revealed, "80 y/o (year old) male pt (patient) went to bed around 10 pm last night and woke up this morning unable to move left side. Pt has history of CVA (cerebral vascular accident) 10 years ago but recovered almost 90% per family members. Today pt is not able to move upper or lower left extremities. Pt is alert but gazing to the right. Pt will respond to following your finger but drifts back to gazing to right as soon as he stops. Pt talks a little garbled but makes since in everything he says. He is able to give personal information and date of current day. V/S (vital signs) taken, accucheck (blood sugar) 89 (normal). 12 lead monitor. Pt was placed on 2 L (liters) 02 (oxygen). Prepared to load. Enroute ER (emergency room) contacted by phone for possible stroke alert. Unsure of onset of S/S (signs and symptoms) due to last time pt was scene (sic) was last night around 10 pm and was fine at that time. Plus pt has history of CVA. Enroute IV (intravenous) started, recheck V/S (extremely hard due to Parkinson's). Once we arrived at ER, nurse came out and advised us that CT (computerized tomography) was down. Pt was given Zofran 4 mg (milligrams) IV and Medic 7 took patient to (Hospital B) ER. ...". Review revealed the ambulance departed Hospital A's DED at 0751 and arrived at Hospital B's DED at 0817.

Review of Hospital A's DED log on 12/16/2013 revealed no evidence Patient #21 had presented to the hospital's DED on 12/09/2013. Interview with administrative staff confirmed there was no medical record for Patient #21 for 12/09/2013.

Closed medical record review of Patient #21 from Hospital B revealed the patient arrived at Hospital B's DED on 12/09/2013 at 0824 and was triaged immediately. Documented vital signs on arrival were: Blood Pressure 154/63, pulse 109, respirations 20, oxygen saturation 97% and temperature 98.6 degrees Fahrenheit orally. Documented chief complaint was left sided weakness, patient unable to move left side with a previous history of CVA (cerebrovascular accident) to left side and regained 90% of use. Further documentation revealed the patient was incontinent of urine, was alert and verbally responsive. Further record review revealed Patient #21 was medically screened by Hospital B's DED physician at 0829. Documentation by the physician at 0859 revealed the patient's left arm and leg was rigid and the patient was unable to move with no sensation on the left. Further record review revealed a CT of the head without contrast was ordered and resulted as nothing acute. Review revealed an EKG was performed and interpreted as atrial fibrillation. Further review revealed the DED physician's diagnosis was cerebral vascular accident and Patient #21 was admitted to Hospital B for further treatment. Review of the dictated history and physical examination for Patient #21 revealed, "...past medical history significant for atrial fibrillation status post pacemaker, not on Coumadin secondary to falls, hypertension, parkinsonism, and previous CVA who presented to the ER for evaluation of left-sided weakness ...Impression: 1. Acute ischemic cerebrovascular accident. He has left-sided hemiplegia (paralysis) ...". Further review revealed the patient was admitted to a telemetry -monitored bed and was discharged to the VA (Veterans Hospital) on 12/09/2013 for rehabilitation. Review of the physician ' s dictated discharge summary, dated 12/12/2013, revealed, "...Significant procedures during the hospitalization: 1. A chest x-ray on admission showed a pacemaker device in place, arthritic changes, and nothing acute. 2. A head CT on admission showed microvascular changes and atrophy with no definite abnormalities identified. 3. A carotid ultrasound showed less than 50% stenosis at the origin of the right ICA, and no hemodynamically significant stenosis was found. ...5. An EKG showed atrial fibrillation at 89. There was some evidence of ventricular pacing and nonspecific changes. ...Hospital Course: ...The patient had left hemiplegia and was having difficulty talking and appeared to have symptoms consistent with a CVA. His head CT did not show any evidence of bleeding. ...He will require aggressive inpatient rehab and he wished to go through the VA medical system for this ....At this point, he is medically stable for transfer ...".

Interview on 12/17/2013 at 0915 with Paramedic #1 revealed the county's EMS (emergency medical services) was dispatched to Patient #21's residence on 12/09/2013 at 0707, with arrival at 0714. Interview revealed, "when we got there, he was laying in the bed. His family member said he had garbled speech and a history of left sided weakness from a previous stroke but that he had recovered 90%. The night before he had been walking around. His relatives said he couldn't get out of bed to use the bathroom. He was incontinent prior to our arrival. His blood pressure was 134/80, oxygen saturation was 96%, heart rate was 100 and respirations were 16. He was doing nothing with his left side. We left his residence around 7:34 and arrived at the EMS dock (Hospital A) at 7:43. I was in the back with the patient. (EMT #1- EMS Driver) called (Hospital A) enroute and told them we had a possible stroke alert. He told them the symptoms and history. Nobody said anything about not bringing him here (Hospital A). My partner said, 'I've got a nurse on the ramp'. I heard someone on the radio say, 'contact us regarding CT being down'. (EMT #1) got out of the truck and the nurse told him the CT was down. They told us to wait a minute. I became concerned that it was taking too long. I stepped out of the truck and asked what was going on. The nurse said, 'our CT is down and we can't do anything for him'. She said, 'wait and let me be sure'. A few minutes passed. (EMT #1) came back and said, 'let's go to (Hospital B). We left about 7:51 and arrived there at 8:17. We went lights and sirens. We needed to get there fast". Interview confirmed Patient #21 was not seen by a nurse or physician at Hospital A.

Telephone interview on 12/17/2013 at 1310 with EMT #2 (Emergency Medical Technician) revealed he was the driver of the ambulance that transported Patient #21 to Hospital A's DED on 12/09/2013. Interview revealed, "I called (Hospital A's) ED and told them (Patient #21's) symptoms. They never said not to come. I was met at the truck before I could get out. The nurse said, 'Hold on just a second. I need to see if the CT scan is still down. I followed her in the ED. A nurse told me to take the patient to (Hospital B). We left and it took us about 30 minutes to get there. We went emergency, lights and sirens". Interview confirmed Patient #21 was not seen by a nurse or physician at Hospital A.

Interview on 12/16/2013 at 1330 with a registered nurse (RN #1) revealed the nurse was working as a staff nurse in Hospital A's DED on 12/09/2013. Interview revealed RN #1 did not have any assigned patients in the DED at 0730 on 12/09/2013. Interview revealed, "I got a phone call from EMS saying they had an 82 year old male having a possible stroke. They told me his vital signs and nothing jumped out as abnormal. I told them I would give a bed assignment on arrival. They called because our radios were down. I got off the phone with them and discussed with (RN #2) which room to put him in. About one minute into our conversation, we remembered the CT scanner was down. The EMS truck showed up at our ambulance entrance about 7:35. I went out and told the driver not to get the patient out because our CT scanner was down and we were trying to figure out whether they needed to take the patient somewhere else. I stood out there while (RN #2) talked to the house supervisor. They decided the patient needed to go somewhere else. They suggested they go to (Hospital B). I did not call (Hospital B)". Interview revealed, "I never went to the back of the EMS truck to see the patient (Patient #21)". Interview further revealed, "(Physician A) heard us talking and he didn't tell us to bring the patient in". Interview confirmed Patient #21 was not medically screened at Hospital A. Interview confirmed Patient #21 had an emergency medical condition when he presented to Hospital A. Interview confirmed Hospital B was not called regarding accepting Patient #21 for transfer. Interview confirmed the hospital's EMTALA policy was not followed.

Interview on 12/16/2013 at 1410 with RN #2 revealed the nurse was the charge nurse for Hospital A's DED on 12/09/2013 beginning at 0700. Interview revealed, "we got a call from EMS that they had a male with left sided paralysis who was normal the night before. I paged CT and the nursing supervisor to find out the status of the scanner. I told the supervisor the truck (EMS) was on its way. During that time, the truck pulled up at the back door. We couldn't decide what to do. The patient needed what we didn't have. I told (RN #1) to tell the truck to hang on just a minute. I asked the driver was he (Patient #21) stable and he said 'yes'. I said, 'can he make it to (Hospital B)'. He said, 'yes'. I told him to take him (Patient #21) to (Hospital B)". Interview revealed RN #2 did not communicate with the DED physician that Patient #21 was at the ambulance entrance with a possible stroke. Interview revealed Hospital A had available beds in the DED when Patient #21 presented via EMS. Interview revealed, "it was my decision to send him to (Hospital B)". Interview confirmed Patient #21 was not medically screened at Hospital A. Interview confirmed Patient #21 had an emergency medical condition when he presented to Hospital A. Interview confirmed Hospital B was not called regarding accepting Patient #21 for transfer. Interview confirmed the hospital's EMTALA policy was not followed.

Interview on 12/16/2013 at 1355 with RN #3 revealed the nurse was the house supervisor at Hospital A on 12/09/2013. Interview revealed, "I knew the CT scanner had been down since the afternoon before (12/08/2013). (RN #2) called me about (Patient #21) at the back door of the ER on the EMS truck. I went over with her that if the patient had a bleed, we didn't have a CT scanner so we couldn't treat him". Interview confirmed Patient #21 was not medically screened at Hospital A. Interview confirmed Patient #21 had an emergency medical condition when he presented to Hospital A. Interview confirmed Hospital B was not called regarding accepting Patient #21 for transfer. Interview confirmed the hospital's EMTALA policy was not followed.

Interview on 12/16/2013 at 1440 with Physician A revealed the physician was working in Hospital A's DED on 12/09/2013 beginning at 0700. Interview revealed, "I overheard that a male patient was coming in with a possible stroke. I was not made aware that he was at the EMS dock". Interview further revealed, "I did not go out to see the patient (Patient #21)". Interview confirmed Patient #21 was not medically screened at Hospital A. Interview confirmed Patient #21 had an emergency medical condition when he presented to Hospital A. Interview confirmed the physician failed to certify that the medical benefits at the time of transfer outweighed the risks of transfer, failed to ensure the receiving facility had accepted the transfer and failed to send related medical records to Hospital B. Interview confirmed the hospital's EMTALA policy was not followed.

Telephone interview on 12/17/2013 at 1105 with Physician B revealed the physician is the medical director for Hospital A's DED. Interview revealed, "I was not made aware of this incident until yesterday. Any patient within 250 feet of our property must be seen by a provider prior to discharge. It is our obligation to evaluate and stabilize a patient prior to discharge. We should have seen this patient (Patient #21). We didn't follow the law".

NC00093795 and NC00093850