HospitalInspections.org

Based on hospital policy review, staff and physician interviews, Hospital documentation reviews, Emergency Medical Services (EMS) documentation review, EMS personnel interviews, Hospital B's (accepting hospital) medical record review, Labor/Delivery (L/D) log review, Hospital A failed to provide an appropriate medical screening examination (MSE) for a patient with an emergency medical condition (EMC) presenting to the DED via ambulance . and failed to maintain an accurate L/D log documenting the disposition of the patient.


The findings include:

1. ~ cross refer to 489.24(r)(3) Central log, Tag A2405.
2. ~ cross refer to 489.24(r) and 480.24(c), Medial Screening Exam, Tag A2406.

Based on hospital policy and procedure review, Labor and Delivery (L/D) log review, and staff interviews, the hospital's L/D nursing staff failed to maintain an accurate log documenting the disposition of the patient.
Findings include:
Review of the hospital policy titled, " EMTALA - Central Log " revised: September 2013 revealed, "The purpose of the Central Log is to track the care provided to each individual who comes to the Hospital seeking care for an Emergency Medical Condition....The Central Log must contain:...the disposition. Permitted dispositions include: 1) Left without Treatment, 2) patient refused treatment, 3) patient was transferred, 4) patient was admitted and treated, 5) patient was stabilized and transferred, 6) patient presented for outpatient test or treatment only, or 7) patient was discharged. "

Review of the log from August, 2014 to March 13, 2015 revealed 27 patients seeking assistance and documentation of the disposition of the patient was missing. Review of the log revealed the areas for documenting the dispositon was blank.

Interview with the Director of Quality (DOQ) on 3/12/2015 at 1400 revealed the staff was not aware documentation of disposition was missing. Interview revealed it is the expectation that the Log contain "disposition of the patient."

Interview with the Director of Nursing (DON) on 3/12/2015 at 1630 revealed the staff was not aware documentation of the disposition was missing. Interview with the DON revealed it is the "expectation that all the elements of EMTALA requirements are to be documented on the log" and that "all staff have been trained" regarding same.

Based on hospital policy review, staff and physician interviews, Hospital documentation reviews, Emergency Medical Services (EMS) documentation review, EMS personnel interviews and Hospital B's (accepting hospital) medical record review, Hospital A failed to provide an appropriate medical screening examination (MSE) and a lack of stabilization for a patient with an emergency medical condition (EMC) in 1 of 1 sampled patients presenting to Hospital A's Dedicated Emergency Department (DED) via EMS (Patient #21).

The findings include:

Review of hospital policy entitled "EMTALA-Medical Screening/Stabilization" revised September, 2013 revealed "In general, when an individual comes, by himself or herself, with another person, or by EMS to the dedicated Emergency department of the Hospital and a request is made on the individual's behalf for a medical examination or treatment, the Hospital (including ancillary services routinely available in the Dedicated Emergency Department and the emergency services offered at outpatient departments or facilities) to determine whether an Emergency Medical condition exists...If an individual arrives a a facility and is not technically in the Dedicated Emergency Department but is on the premises of the Hospital and requests emergency care, he of she is entitled to a Medical Screening Examination...Once a patient presents to the Dedicated Emergency Department of the hospital whether by ambulance or otherwise, the hospital has an obligation to see the patient. A hospital's EMTALA obligations begin when the patient presents at the hospital Dedicated Emergency Department on hospital property, or is picked up by a Hospital-owned ambulance, and a request is made for examination or treatment of an emergency medical condition. Patients arriving via ambulance meet this requirement when the ambulance staff requests treatment from hospital staff. Ambulance Parking is not appropriate and could result in an EMTALA violation".

Review of hospital policy titled "Emergency Medical Treatment and Patient Transfer" revised Sept. 2013 revealed "...Hospital Property or Premises includes the entire main Hospital campus, including the parking lot, sidewalk and driveway...Medical Screening Examination is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists...Such screening must be done with the Hospital's capacity and capability and available personnel, including on-call physicians. The Medical Screening Examination is an ongoing process".

Interview with hospital A's administrative staff (Nursing DED Director, Chief Executive Officer, DED Medical Director, Nursing supervisor #1, Chief Nursing Officer and Risk Management staff #1) on 03/11/2015 at 1612 revealed the staff discussing a concern of a patient that came to the hospital campus by EMS. The interview revealed the patient did not have a MSE. The interview revealed the hospital could not take the patient into the ED per the ED Medical Director because that would be accepting a patient from a higher level of care to a lower level of care. The higher level of care was from a hospital Intensive Care unit to an ED. The interview revealed that this also was not an emergency transport but a routine transport from a hospital to a another hospital. The interview revealed the paramedics did not request emergency services but only requested medication. The interview revealed after discussion the decision was made that the hospital could not accept the patient.

Interview with Nursing Supervisor #1 on 03/11/2015 at 1614 revealed on 02/16/2015 the area was having a snow storm. The interview revealed he had received a phone call from another counties paramedic that was transporting a patient from hospital C to a Tertiary Care hospital. The interview revealed the ambulance was approximately 10 miles from the hospital on the interstate and was turning around due to the weather and concern for not having enough medication for the patient. The interview revealed he talked with the ED Medical Director who was working in the ED at the time. The interview revealed the ED Medical Director told him it was not appropriate to accept the patient to the ED. The interview revealed the Administrator on-call was contacted and the decision was made the hospital would not accept the patient. The interview revealed he tried to contact EMS back and was unable to make contact. The interview revealed the EMS ambulance was in the ED "bay" for ambulances. The interview revealed EMS told him they were concerned about the "icy conditions" and running out of medication for the patient. The interview revealed the EMS staff were concerned about running out of Diprovan (Propofol). The interview revealed EMS stayed in the hospital bay about 20 minutes and then left. The interview revealed about 2 hours after EMS left he received a phone call from a physician in the ED at Hospital B and he was "given a heads up" about a patient brought in by EMS that was in the ED at Hospital B.

Interview on 03/11/2015 at 1630 with the ED Medical Director revealed the patient could not be taken in by the hospital ED because this was a routine transport not an emergency transport, he did not have any information about the patient that was a post surgery, EMS was asking for medications only and were not requesting emergency services.

Review of hospital documentation of a timeline of events received on 03/12/2015 at 1620 revealed on 02/16/2015 at approximately 1820, a call was received from EMS to the Nursing Supervisor regarding the fact that EMS "had driven past our hospital by 10 miles and were coming back to us due to weather. The paramedic stated the patient was on a ventilator and they were concerned about running out of sedation due to traffic/weather conditions". Review revealed the nursing supervisor spoke with the ED Medical Director and the Administrator on call. The "collective decision was made it would not be appropriate to accept the patient into the ED for the following reasons: This was a hospital to hospital transfer and not an emergent situation. Patient did not require screening or stabilization per EMS." The hospital "did not have capability (SICU) to care for this patient". Review revealed at approximately 1840, EMS had pulled into the ambulance bay and the supervisor went to the ambulance and met with the paramedic. EMS medic told supervisor they were concerned with the weather and having enough medication. The supervisor asked if the patient needed emergency stabilization and "she replied "no"." The supervisor offered medication for the patient and "the crew was unsure what to do". Review revealed at approximately 1900 the ambulance remained in the bay. The supervisor went back to the ambulance and spoke with the same female member of the crew and "she stated they didn't know what to do at this point". Review revealed at 1900 the ambulance was "noted to have vacated the ambulance bay."

Review of the CNO 24 hour report dated 02/16/2015 revealed "Notes: Name of ambulance transporting surgical patient from Name of Hospital C to tertiary care hospital unable to transport d/t (due to) weather attempted to bring to ED;AOC (Administrator on call) (name), EDP (ED physician (name of DED medical director and AOC conferred and came to decision it would be inappropriate to accept patient to Name of hospital A's ED. EMS was advised to contact medical control for instructions (return to Name of hospital C) or attempt to locate another accepting MD at an acceptable facility.) EMS was notified that if they needed any medication or if patient was acutely unstable the ED could assist, but they advised patient was stable, they thought they could not make it to name of tertiary care hospital because of the weather".

Review of EMS Patient Care Record (PCR) revealed on 02/16/2015 at 1930, EMS picked up patient #21 at Hospital C (transferring hospital) for transport to a Tertiary Care hospital. Review of the PCR revealed the patient was intubated, on a ventilator and on a Propofal (anesthetic sedation medication) 20 mcg/kg/min IV. PCR review revealed the patient was administered Dilaudid 2 mg by nursing staff prior to the patient being loaded into the ambulance. Further review revealed "During transport found that the weather and road conditions had gotten worse and we had to slow down to 25 mph and was stuck in traffic for a little bit due to a MVC (motor vehicle crash). Just after passing XXX (name of hospital A) exit and having several vehicles wreck in front of us,and almost hitting us, we made the decision to stop at a local hospital due to it being too dangerous for us and the patient to go to YYY(name of tertiary care hospital). We contacted 301 and advised them of the same and were told to go to a local/closest hospital with the (patient) pt. We contacted ZZZ (name of critical access hospital) and they advised us that they were unable to handle the pt due to no respiratory techs on site. We turned around and headed back to name of hospital A in Statesville and contacted them regarding the pt and our ETA (estimated time of arrival). We talked to a supervisor and they stated to come on. Upon arriving at hospital A, we were met in the ambulance bay by staff and was told that they would not be acccepting (sic) the pt per their CEO, that we would have to call our medical control, and find another hospital. We contacted 301 and advised of what had happened and were told to stand by while he called 300. We were contacted by 300 and explained what was going on and why we diverted and what was said on our arrival to name of hospital A. Were told by 300 to call Hospital C and talk to the ER doc and see what to do. Did the same and talked with Dr. X (ED physician at hospital C), and was told to standby while he contacted a supervisor. While waiting to hear back from same, contacted name of hospital B and explained what was going on and name of Hospital B stated to come on. Advised Hospital C and 300 of same and transported pt to same. Once at name of hospital B, moved the pt from the truck and into the ER and to room 4. Once in the room moved the pt to the pt to the bed and respiratory put the pt on their vent. Gave report to the nurse and the doctor and explained why were were stopping and not continuing to name of Tertiary Care hospital. The nurse and the doctor stated they understood and they were goring to call hospital C and get more pt info...".

Interview with Paramedic #1 and EMT #1 on 03/19/2015 at 0834 revealed he (paramedic) and (EMT) she were on duty for the transport for patient #21 on 02/16/2015. The interview revealed the paramedic provided care to the patient and the EMT was the driver. The interview revealed the patient was on a Propofol IV to keep the patient sedated during transport because the patient was on the ventilator and they did not want the patient to pull the ET tube out. The interview revealed the Propofol was started at Hospital C. The interview revealed during the transport the weather, (snow) had gotten "bad". The interview revealed the ambulance was almost in an accident. The interview revealed the ambu;lance had stopped on the interstate due to a weather related accident. The interview revealed they contacted the EMS shift supervisor and they were directed to go to the closest hospital. The interview revealed after contacting one hospital in which it was noted the hospital did not have respiratory technicians, the decision was made to turn around and go to Hospital A. The interview revealed the nursing supervisor was contacted by phone at Hospital A and was told the need to "divert because it was no longer safe to transport". The interview revealed the supervisor told them he understood and to bring the patient to Hospital A. The interview revealed the estimated time of arrival was given to the supervisor of 10 minutes. The interview revealed upon arrival at the ambulance bay at the ED at Hospital A the EMT (Emergency Medical Technician-Basic) was met by an RN as she (EMT) opened the door to get out. The interview revealed she was told "His CEO had instructed him "you" could not bring the patient into Hospital. The interview revealed the RN was "apologetic" and asked if the patient was coding. The interview revealed the RN was asked "had something changed". The interview revealed the RN went back into the hospital. The interview revealed the EMS supervisor was contacted and the patient was becoming more alert and agitated, as if in pain. The interview revealed the RN returned opening the front cab door of the ambulance and asked how long they would be there. The interview revealed the RN was told "did not know trying to see what the next step was". The interview revealed the RN never talked with the paramedic and did not assess or view the patient. The interview revealed they went to Hospital B as directed.

Closed medical record review from Hospital B (accepting hospital) for patient #21, a 63 year old revealed the patient presented to the Hospital B's DED on 02/16/2015 at 1955. Record review revealed the patient was being transferred from Hospital C to a tertiary care hospital and due to "severely bad road conditions" the patient was brought to the DED. Record review revealed the patient had a medical screening exam in the DED and a surgical consultation and was admitted to the Intensive Care Unit.

NC00104478