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Based on interview, record review and policy review, the hospital failed to follow its policies and provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#23) of 24 Emergency Department (ED) records reviewed from 10/01/23 through 05/19/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an Emergency Medical Condition (EMC).

Findings included:

Review of hospital policy, "Medical Screening Exam," dated 04/2021, showed once a patient enters a Citizen's Memorial Hospital (CMH)-owned ambulance, the patient is considered as presented to hospital property and should be transported to CMH's ED, provided a MSE and stabilizing treatment within the hospital's capability and capacity. The hospital is obligated to provide an MSE so the presence of an EMC, or lack thereof, can be identified.

Review of hospital policy, "Ambulance Medical Control," dated 12/2022, showed whenever medical control of patient care is required during an emergency, it should be provided by the Emergency Room physician at the receiving hospital.

Review of the hospital's online Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) protocol, "Trauma Arrest," revised 03/19/23, showed that for the adult trauma patient, with a narrow complex pulseless electrical activity (PEA, where the electrocardiogram [record of the electrical signal from the heart] shows a heart rhythm that should produce a pulse, but does not) rhythm, resuscitation efforts should not be terminated in the field.

Review of Patient #23's EMS Trip Ticket, dated 04/14/24 showed the following:
- At 10:40 PM, EMS was dispatched to the scene of a gunshot wound (GSW) to the head in cardiac arrest (when the heart suddenly and unexpectedly stops pumping).
- At 10:55 PM, EMS arrived on scene.
- At 10:59 PM, intubation (process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own) was attempted but unsuccessful. He lost his pulse and cardiopulmonary resuscitation (CPR, emergency life-saving procedure performed when a person's breathing or heartbeat has stopped) was initiated.
- At 11:08 PM, he was successfully intubated.
- At 11:16 PM, CPR was stopped. Patient #23 was in a sinus tachycardia (an increased heart rate that exceeds 100 beats per minute [bpm]) with a heart rate of 127 bpm.
- At 11:21 PM, transport to CMH ED began.
- At 11:27 PM, he went into cardiac arrest again and CPR was initiated.
- The patient did not receive defibrillation (Delivers an electric shock to the heart to allow it to get out of a potentially fatal abnormal heart rhythm).
- At 11:32 PM, Patient #23 was in ventricular fibrillation (V-Fib, an abnormal heart rhythm that can lead to sudden cardiac death). Resuscitation was terminated and patient's time of death was 11:32 PM.
- A non-timed narrative entered by Staff R, Paramedic, showed Staff H, EMS Regional Manager, rode in the ambulance with the patient. During transport, Staff H called CMH for report. During Staff H's call to the ED, Patient #23 lost pulses and CPR was restarted. Staff H ended the call. Staff H then called the ED back and requested to speak to Medical Control. During this call, the patient was in PEA without a pulse. Staff H informed the EMS crew to stop CPR as directed by Medical Control. CPR was discontinued approximately one minute before the ambulance arrived at the ED. After CPR was discontinued, Staff R felt she could feel a thready pulse and found the patient was in a bradycardic (slow heart rate) rhythm. When EMS arrived at the ED, Staff H entered the ED to speak with the physician. It was requested that the physician come out and evaluate the patient. Staff H then returned to the ambulance and stated Staff M, Physician, and Staff L, Charge Registered Nurse (RN) refused to allow the patient in the ED since he had already died. The patient remained in the ambulance until the Polk County coroner arrived on scene.

Based on interview, record review and policy review, the hospital failed to follow its policies and provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#23) of 24 Emergency Department (ED) records reviewed from 10/01/23 through 05/19/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an Emergency Medical Condition (EMC).

Findings included:

Review of hospital policy, "Medical Screening Exam," dated 04/2021, showed once a patient enters a Citizen's Memorial Hospital (CMH)-owned ambulance, the patient is considered as presented to hospital property and should be transported to CMH's ED, provided a MSE and stabilizing treatment within the hospital's capability and capacity. The hospital is obligated to provide an MSE so the presence of an EMC, or lack thereof, can be identified.

Review of hospital policy, "Ambulance Medical Control," dated 12/2022, showed whenever medical control of patient care is required during an emergency, it should be provided by the Emergency Room physician at the receiving hospital.

Review of the hospital's online Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) protocol, "Trauma Arrest," revised 03/19/23, showed that for the adult trauma patient, with a narrow complex pulseless electrical activity (PEA, where the electrocardiogram [record of the electrical signal from the heart] shows a heart rhythm that should produce a pulse, but does not) rhythm, resuscitation efforts should not be terminated in the field.

Review of Patient #23's EMS Trip Ticket, dated 04/14/24 showed:
- At 10:40 PM, EMS was dispatched to the scene of a gunshot wound (GSW) to the head in cardiac arrest (when the heart suddenly and unexpectedly stops pumping). CMH ED activated their trauma team.
- At 10:55 PM, EMS arrived on scene.
- At 10:59 PM, intubation (process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own) was attempted but unsuccessful. He lost his pulse and cardiopulmonary resuscitation (CPR, emergency life-saving procedure performed when a person's breathing or heartbeat has stopped) was initiated.
- At 11:05 PM, intubation was attempted again, but unsuccessful. CPR continued.
- At 11:08 PM, he was successfully intubated.
- At 11:14 PM, 1 milligram (mg) epinephrine (a hormone and medication used along with emergency medical treatment to treat life-threatening conditions) was administered.
- At 11:16 PM, CPR was stopped. Patient #23 was in a sinus tachycardia (an increased heart rate that exceeds 100 beats per minute [bpm]) with a heart rate of 127 bpm.
- At 11:21 PM, transport to CMH ED began.
- At 11:27 PM, he went into cardiac arrest and CPR was initiated.
- The patient did not receive defibrillation (Delivers an electric shock to the heart to allow it to get out of a potentially fatal abnormal heart rhythm).
- At 11:32 PM, Patient #23 was in ventricular fibrillation (V-Fib, an abnormal heart rhythm that can lead to sudden cardiac death). Resuscitation was terminated and patient's time of death was 11:32 PM.
- A non-timed narrative entered by Staff R, Paramedic, showed Staff H, EMS Regional Manager, rode in the ambulance with the patient. During transport, Staff H called CMH for report. During Staff H's call to the ED, Patient #23 lost pulses and CPR was restarted. Staff H ended the call. Staff H then called the ED back and requested to speak to Medical Control. During this call, the patient was in PEA without a pulse. Staff H informed the EMS crew to stop CPR as directed by Medical Control. CPR was discontinued approximately one minute before the ambulance arrived at the ED. After CPR was discontinued, Staff R felt she could feel a thready pulse and found the patient was in a bradycardic (slow heart rate) rhythm. When EMS arrived at the ED, Staff H entered the ED to speak with the physician. It was requested that the physician come out and evaluate the patient. Staff H then returned to the ambulance and stated Staff M, Physician, and Staff L, Charge Registered Nurse (RN) refused to allow the patient in the ED since he had already died. The patient remained in the ambulance until the Polk County coroner arrived on scene.

Although requested, Staff P, Trauma Surgeon, was out of the country and could not be reached for an interview.

During an interview on 05/22/24 at 11:30 AM, Staff R, Paramedic, stated that Staff H, EMS Regional Manager called the ED for report while Patient #23 was being transported. The first call ended prematurely because Patient #23 had lost his pulse and resuscitation efforts had to be restarted. At some point during resuscitation efforts, Staff H made a second call to the ED and requested to speak to Medical Control. Staff H informed them that per Medical Control and the trauma surgeon on-call, resuscitation efforts needed to be stopped. CPR was stopped and was not being performed when they arrived at the hospital. Staff H entered the hospital when they arrived and when he returned to the ambulance, he informed them that the ED would not take the patient. She stated that she instructed Staff H to go back into the ED and request the physician come out to have the patient evaluated. When Staff H returned to the ambulance for the second time, he stated that they would not take the patient. She felt Patient #23 was denied entry into the ED, but she did not go into the ED herself and make a request for Patient #23 to be evaluated. She had no direct communication with the ED staff or physician about the patient, during transport or when they arrived at the ED.

During an interview on 05/21/24 at 10:45 AM, Staff H, EMS Regional Manager, stated that during transport, he called the ED to give report on the patient. At that time the patient had a pulse. While he was still on the phone, the patient lost his pulse and CPR was restarted, so he abruptly ended the call to tend to the patient. Once he felt the other EMS crew had the situation under control, he called the ED back and requested to speak to Medical Control. During the second call, it was decided by Staff M, Physician, in consultation with the on-call trauma surgeon, to have resuscitation efforts terminated. When they arrived at the ED, he stated that Staff L, Charge RN, instructed him to not bring Patient #23 into the ED as they did not want to complete paperwork associated with a patient death.

During a telephone interview on 05/21/24 at 2:45 PM, Staff L, Charge RN, stated that she received two phone calls from EMS about Patient #23. During the first call, EMS provided her with a patient report, but the call was prematurely ended. During the second call, Staff H requested to speak with Medical Control, so she connected Staff H to Staff M, Physician. Shortly after that call, Staff H entered the ED and asked, "What do you want us to do with the dead body?" Staff L stated that it was never mentioned that Patient #23 had achieved return of spontaneous circulation (ROSC) or had any signs of life.

During a telephone interview on 05/21/24 at 3:10 PM, Staff M, Physician, stated that he received a call for Medical Control of Patient #23. When he spoke with Staff H, he was informed that the patient had a GSW to the head, in PEA, and that resuscitation efforts had been underway for 30 minutes. He consulted Staff P, Trauma Surgeon, who instructed him to have resuscitation efforts terminated. When the ambulance arrived at the ED, Staff H entered and asked, "What do you want us to do with the body?" Staff M was not informed that the patient was not deceased, that the patient had a pulse, or any signs of life. He was under the impression that resuscitation efforts were discontinued while en route and Patient #23 had died prior to his arrival at the ED. No paramedics came into the ED and requested that he go out to the ambulance to assess the patient for potential signs of life. He stated that EMS did not typically leave a patient in the ambulance to enter the ED and request a physician come out to the ambulance and perform a MSE. EMS brought patients into the ED, so an MSE could be performed, and stabilizing treatment provided, if applicable. Staff M stated that if it had been requested, he would have gone out to the ambulance and evaluated the patient.

Based on interview, record review, and policy review, the hospital failed to ensure that emergency medical conditions (EMC) were stabilized for two patients (#23 and #24) out of 24 Emergency Department (ED) sample cases reviewed from 10/01/23 through 05/19/24, when they were discharged or transferred with unstable medical conditions. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for and Emergency Medical Condition (EMC).

Findings included:

Review of the hospital's policy titled, "Ambulance Medical Control," dated 12/2022, showed that whenever medical control of patient care was required during an emergency, it should be provided by the ED physician at the receiving hospital.

Review of the hospital's online Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) protocol titled, "Trauma Arrest," revised 03/19/23, showed that for the adult trauma patient, with a narrow complex pulseless electrical activity (PEA, where the electrocardiogram [record of the electrical signal from the heart] shows a heart rhythm that should produce a pulse, but does not) rhythm, resuscitation efforts should not be terminated in the field.

Review of the hospital's online EMS Protocol, "Cardiac Arrest," revised 04/27/23, showed for victims of trauma with no signs of life, field termination of resuscitation efforts may be requested from Medical Control. Field termination of resuscitation efforts may be requested regardless of how long resuscitation efforts have been underway.

Review of Patient #23's EMS Trip Ticket, dated 04/14/24 showed:
- At 11:16 PM, Patient #23 was in a sinus tachycardia (an increased heart rate that exceeds 100 beats per minute [bpm]) with a heart rate of 127 bpm with a pulse. The patient was prepared and moved to the ambulance.
- At 11:21 PM, Patient #23 was secured in the ambulance and transported to Citizens Memorial Hospital's (CMH) ED.
- At 11:27 PM, Patient #23 went into cardiac arrest and CPR was initiated.
- The patient did not receive defibrillation (delivers an electric shock to the heart to allow it to get out of a potentially fatal abnormal heart rhythm).
- At 11:32 PM, Patient #23 was in ventricular fibrillation (V-Fib, an abnormal heart rhythm that can lead to sudden cardiac death). Resuscitation was terminated and patient's time of death was 11:32 PM.
- A non-timed narrative entered by Staff R, Paramedic, showed Staff H, EMS Regional Manager, rode in the ambulance with the patient. During transport, Staff H called CMH for report. During Staff H's call to the ED, Patient #23 lost pulses and CPR was restarted, so Staff H ended the call. Staff H then called the ED back and requested to speak to Medical Control. During this call, the patient was in PEA without a pulse. Staff H informed the EMS crew to stop CPR as directed by Medical Control. CPR was discontinued approximately one minute before the ambulance arrived at the ED. After CPR was discontinued, Staff R felt she could feel a thready pulse and found the patient was in a bradycardic (slow heart rate) rhythm. When EMS arrived at the ED, Staff H entered the ED to speak with the physician. It was requested that the physician come out and evaluate the patient. Staff H then returned to the ambulance and stated Staff M, Physician, and Staff L, Charge Registered Nurse (RN) refused to allow the patient in the ED since he had already died. The patient remained in the ambulance until the Polk County coroner arrived on scene.

Although requested, Staff P, Trauma Surgeon, was out of the country and could not be reached for an interview.

During an interview on 05/22/24 at 11:30 AM, Staff R, Paramedic, stated that Staff H, EMS Regional Manager called the ED for report while Patient #23 was being transported. The first call ended prematurely because Patient #23 had lost his pulse and resuscitation efforts had to be restarted. At some point during resuscitation efforts, Staff H made a second call to the ED and requested to speak to Medical Control. Staff H informed them that per Medical Control and the trauma surgeon on-call, resuscitation efforts needed to be stopped. CPR was stopped and was not being performed when they arrived at the hospital. Staff H entered the hospital when they arrived and when he returned to the ambulance, he informed them that the ED would not take the patient. She stated that she instructed Staff H to go back into the ED and request the physician come out to have the patient evaluated. When Staff H returned to the ambulance for the second time, he stated that they would not take the patient. She felt Patient #23 was denied entry into the ED, but she did not go into the ED herself and make a request for Patient #23 to be evaluated. She had no direct communication with the ED staff or physician about the patient, during transport or when they arrived at the ED.

During an interview on 05/21/24 at 10:45 AM, Staff H, EMS Regional Manager, stated that during transport, he called the ED to give report on the patient. At that time the patient had a pulse. While he was still on the phone, the patient lost his pulse and CPR was restarted, so he abruptly ended the call to tend to the patient. Once he felt the other EMS crew had the situation under control, he called the ED back and requested to speak to Medical Control. During the second call, it was decided by Staff M, Physician, in consultation with the on-call trauma surgeon, to have resuscitation efforts terminated. When they arrived at the ED, he stated that Staff L, Charge RN, instructed him to not bring Patient #23 into the ED as they did not want to complete paperwork associated with a patient death.

During a telephone interview on 05/21/24 at 2:45 PM, Staff L, Charge RN, stated that she received two phone calls from EMS about Patient #23. During the first call, EMS provided her with a patient report, but the call was prematurely ended. During the second call, Staff H requested to speak with Medical Control, so she connected Staff H to Staff M, Physician. Shortly after that call, Staff H entered the ED and asked, "What do you want us to do with the dead body?" Staff L stated that it was never mentioned that Patient #23 had achieved return of spontaneous circulation (ROSC) or had any signs of life.

During a telephone interview on 05/21/24 at 3:10 PM, Staff M, Physician, stated that he received a call for Medical Control of Patient #23. When he spoke with Staff H, he was informed that the patient had a GSW to the head, in PEA, and that resuscitation efforts had been underway for 30 minutes. He consulted Staff P, Trauma Surgeon, who instructed him to have resuscitation efforts terminated. When the ambulance arrived at the ED, Staff H entered and asked, "What do you want us to do with the body?" Staff M was not informed that the patient was not deceased, that the patient had a pulse, or any signs of life. He was under the impression that resuscitation efforts were discontinued while en route and Patient #23 had died prior to his arrival at the ED. No paramedics came into the ED and requested that he go out to the ambulance to assess the patient for potential signs of life. He stated that EMS did not typically leave a patient in the ambulance to enter the ED and request a physician come out to the ambulance and perform a MSE. EMS brought patients into the ED, so an MSE could be performed, and stabilizing treatment provided, if applicable. Staff M stated that if it had been requested, he would have gone out to the ambulance and evaluated the patient.

Review of Patient #24's medical record from Hospital B, dated 10/07/24, showed:
- She was an 81-year-old female with a history of dementia (a loss of thinking abilities and memory) who was brought to the ED by police, on 10/06/23, for a psychiatric (relating to mental illness) evaluation after exhibiting erratic behavior. She was placed on a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others).
- The patient was medically cleared for transfer to a psychiatric facility.
- Hospital B contacted CMH and the patient was accepted for admission to the geriatric psychiatric (Geropsych, a unit that focuses on treating mental health and psychiatric disorders in older adults) unit and given a room assignment. Transport was scheduled with the Vernon County Ambulance District (VCAD).
- VCAD picked up the patient at approximately 9:00 AM. At 10:09 AM Hospital B was notified that a physician at CMH refused the transfer. VCAD returned with the patient to Hospital B where she was re-evaluated in the ED and held for placement in another facility.

Review of Patient #24's VCAD's Patient Care Report, dated 10/07/24, showed the patient was picked up from Hospital B at 9:19 AM and transported to CMH. Upon arrival they were informed by hospital staff that the patient would not be accepted. VCAD staff waited while the ED physician contacted Hospital B. They were instructed by Hospital B to return with the patient. The patient's vital signs were recorded at regular intervals throughout the trip.

During an interview on 05/21/24 at 3:05 PM, Staff N, VCAD Emergency Medical Technician (EMT), stated he transported the patient from Hospital B to CMH. He stated that upon arrival the hospital wouldn't accept the patient and they were instructed by Hospital B to return with the patient. He stated that the patient's condition remained unchanged during the trip and didn't require medical intervention. The patient remained in the ambulance.
Review of Patient #24's medical record, dated 10/07/23, showed only the patient's registration information including address, allergies, diagnosis, insurance information and family contacts.
During an interview on 05/22/24 at 9:30 AM, Staff D, Nursing Operations Director, stated that the hospital's review of Patient #24's transfer request showed:
- Hospital B requested a transfer to CMH's geropsych unit on 10/06/24.
- The hospital accepted the patient at approximately 3:00 AM on 10/07/24 and began completing registration information in the hospital's electronic medical record.
- The acceptance was not communicated to the oncoming shift.
- EMS arrived at the hospital's ambulance bay with the patient at approximately 10:00 AM on 10/07/24. The geropsych unit was unaware of the transfer and refused to accept the patient. The ED physician was notified of the patient's presence but with no knowledge of the transfer was concerned it could be patient dumping.
- The ED physician consulted with hospital administration and decided to contact Hospital B to discuss placement. If a solution had not been reached with Hospital B the patient would have been evaluated by CMH's ED staff. Hospital B was contacted and agreed to have the patient returned by EMS.
- The patient was transported by EMS back to Hospital B.

Based on interview, policy review and record review, the hospital failed to accept one patient (#24) from another hospital out of 24 Emergency Department (ED) records reviewed. The hospital's ED average monthly census over the past six months was 1,269.

Findings included:

Review of Patient #24's medical record from Hospital B, dated 10/07/24, showed:
- She was an 81-year-old female with a history of dementia (a loss of thinking abilities and memory) who was brought to the ED by police on 10/06/23 for a psychiatric (relating to mental illness) evaluation after exhibiting erratic behavior. She was placed on a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others).
- The ED physician completed a medical screening examination (MSE) and recommended placement in a geriatric facility and her guardian agreed.
- The patient was medically cleared for transfer to a psychiatric facility.
- Hospital B contacted several facilities for placement and the patient was accepted for admission to Citizen's Memorial Hospital's (CMH) geropsych unit on 10/07/24 at 2:30 AM and given a room assignment. Her RN called CMH and gave a report to the receiving nurse and scheduled transportation with the Vernon County Ambulance District (VCAD).
- VCAD picked up the patient at approximately 9:00 AM. At 10:09 AM, Hospital B was notified that a physician at CMH had refused the transfer. VCAD returned with the patient to Hospital B where she was re-evaluated in the ED and held for placement in another facility.

Review of Patient #24's CMH medical record, dated 10/07/23, showed only the patient's registration information including address, allergies, diagnosis, insurance information and family contacts.

Review of Patient #24's VCAD's Patient Care Report, dated 10/07/24, showed the patient was picked up from Hospital B by EMS at 9:19 AM and transported to CMH. Upon arrival they were informed by CMH staff that the patient would not be accepted. VCAD staff waited while the ED physician contacted Hospital B. They were then instructed by Hospital B to return with the patient.

During an interview on 05/21/24 at 3:05 PM, Staff N, VCAD EMT, stated that he transported the patient from Hospital B to CMH. He stated that upon arrival, CMH wouldn't accept the patient due to a problem with the patient's legal guardianship and that they were instructed by Hospital B to return with the patient.

During an interview on 05/22/24 at 9:30 AM, Staff D, Nursing Operations Director, stated that the hospital's review of Patient #24's transfer request showed:
- Hospital B requested a transfer to CMH's geropsych unit on 10/06/24.
- The hospital accepted the patient at approximately 3:00 AM on 10/07/24 and began completing registration information in the hospital's electronic medical record. It was unclear if all admission requirements were met, including the hospital speaking with the patient's legal guardian to obtain consent to admit her. The hospital did not have documentation of the patient's legal guardianship.
- The acceptance was not communicated to the oncoming shift.
- EMS arrived at the hospital's ambulance bay with the patient at approximately 10:00 AM on 10/07/24. The geropsych unit was unaware of the transfer and refused to accept the patient. The ED physician was notified of the patient's presence but with no knowledge of the transfer was concerned it could be patient dumping.
- Staff present overnight when the transfer was requested were not contacted for clarification.
- The ED physician consulted with hospital administration and decided to contact Hospital B to discuss placement. Hospital B was contacted and agreed to have the patient returned by EMS.
- The patient was transported by EMS back to Hospital B.

During an interview on 05/21/24 at 11:15 AM, Staff G, Geriatric Psychiatry Department Supervisor, stated that she did not recall patient #24.

During a telephone interview on 05/21/24 at 11:00 AM, Staff I, Physician, stated that he did not recall Patient #24. Patients that had been medically cleared were admitted directly to the geriatric psychiatric unit.

During an interview on 05/20/24 at 3:35 PM, Staff D, Nursing Operations Director, stated that transfer patients that are medically cleared prior to arrival were admitted directly to the geriatric psychiatric unit.

During an interview on 05/21/24 at 3:35 PM, Staff O, former Quality Director, stated that she spoke with Hospital B concerning the transfer and reviewed the circumstances of the transfer. She stated that the requirement for guardianship documentation and consent were not met.