HospitalInspections.org

Based on review of facility documents and employee interviews (EMP), it was determined that the facility failed to maintain a central log of each individual who comes to the emergency department for one of 21 patients (PT1).

Findings include:

Review of policies on August 21, 2013, at approximately 1:00 PM revealed no specific policy regarding EMTALA provisions and staff requirements/response.

Review of the facility online training "CD379/Emergency Care Is a Patient's Right - Insured or Not," no date, on August 21, 2013, at approximately 2:00 PM revealed, "Course Objectives The goal of this program is to educate nurses about the fundamental requirements of the Emergency Medical Treatment and Labor Act. ... Other key points for RNs ... Logs: Hospitals must maintain a central log of people who come to the DED (Dedicated Emergency Department) seeking treatment and indicate their disposition (i.e., refused treatment, admitted, discharged)."

Review of facility online training "The "20 Commandments" of Cobra/EMTALA" on August 21, 2013, at approximately 2:30 PM revealed, "1. THOU SHALL: Log in every patient who presents, together with complaint/diagnosis and disposition. A patient has "presented" when they enter onto the premises, campus (and 250 yard zone around the hospital), "provider based" remote sites and ambulances owned by the hospital without regard of means or ability to pay."

1. Review of an (EMS Provider) Trip Sheet dated August 19, 2013, revealed the ambulance crew arrived at the nursing care facility at 4:41 AM on August 19, 2013, to transport the patient. The report revealed, "... The patient's [family member] and the mental health delegate advised 'the patient would be transported to jameson hospital for the psych evaluation and 302 commitment' ... (4:54 AM) transporting to jameson hospital. ... (5:01 AM) ... arrived at jameson hospital, the patient was removed from the back of the ambulance still secured onto the multi level stretcher, while walking toward the emergency room entrance, the crew was stopped from entering the emergency room by [EMP3-emergency room RN] crew was advised by [EMP3] 'not to bring the patient into the emergency dept, that they were not going to take the patient' at that time [EMP3] told the crew to hold on and [EMP3] went into the emergency department and got the psych nurse who also came to the entrance door and stated 'the patient was not going to be seen there, they didn't have any open beds and that the crew would have to transport the patient to the [Other acute care facility] for the psych evaluation' I asked the psych nurse if the patient's [family member] was aware of the change [he/she] stated '[he/she] would advise [family member] of the change'... (5:06 AM) ... the patient was reloaded into the back of the ambulance for transport to [Other acute care facility] ... (5:27 AM) ... at [Other acute care facility] the patient was taken into the emergency dept ... patient report was given to RN [OTH12], [OTH12] was advised of the reason the patient was being brought into this facility and that the patient had originally been transported to jameson and they refused the patient into their facility, [OTH12] documented all the info on a patient treatment sheet and assumed care of the patient from the crew at that time." The bottom of the form revealed the following, "Transportation Factors Affecting Care: Other: jmh (Jameson Memorial Hospital) refused patient access to emergency room."

2. On August 21, 2013, at 9:10 AM, EMP3 confirmed the ED physician was unaware of the patient being there (Jameson Hospital) and being diverted to (Other acute care facility) stating, "No. [ED physician] was not. At the time, we didn't think it was a situation." When asked to confirm that the patient was not seen by Jameson staff, made a Jameson patient or added to the ED log, EMP3 stated, "Correct."

3. On August 21, 2013, at 10:23 AM, when asked if ED employees know that once an ambulance arrives on the property, EMTALA applies, EMP2 stated, "Yes. They do."

Further interview with EMP2 confirmed that the patient was on hospital property. When asked if the patient should have been evaluated, EMP2 stated, "Absolutely."

4. During a telephone interview at approximately 11:00 AM on August 22, 2013, when asked what OTH14 recalled of the events surrounding the other facility's receipt of the patient, OTH14 stated, "... We had parked ten to fifteen feet away from the hospital, where we take the patients in. ... We had the patient out of the ambulance, under the overhang, and [EMP3] stopped us ... and we had to load [patient] back up. ... We were initially told the patient would go to Jameson for a psych evaluation and then go to [other facility] for admission. ... [OTH1] and the [patient family member] were out at the triage where they do registration [at Jameson when the ambulance was unloading the patient]. ..."

5. Review of the ED Log for August 19, 2013, did not reveal the patient's name. Interview on August 21, 2013, at 9:35 AM, with EMP2 confirmed the patient was not listed in the log.

Based on review of facility documents and medical records (MR), and employee interviews (EMP), it was determined that the facility failed to provide an appropriate medical screening examination for one of 21 MR (MR1).

Findings include:

Review of Policy No.02.104, "BHS Emergency Department Assessment and Admission Procedure," reviewed/revised March 2013, revealed, "... 2.0 Directive 1. All BHS patients will be triaged by the Emergency Department RN according to individual needs. ... 7. The basic interview takes place between the Emergency Department RN and the patient. The ER RN will maintain documentation in the progress record of the ER Chart. 8. The Emergency Department physician sees the patient and if needed, orders a psychiatric assessment. The Inpatient Behavioral Health Unit is contacted by the ER of the needed mental health assessment. ... Behavioral Health Services then deploy an ER on call Mental Health Assessment staff member to assess the patient within 30 minutes. 9. The Mental Health ER assessment staff member documents the assessment on the BHS Clinical Assessment Form ... This assessment form is scanned into MedHost and becomes a part of the patient's permanent record. If admitted, the original is sent with the patient to BHS and a copy is made and kept to scan into the ER record. 10. The BHS Mental Health Assessment staff gives a report to the Emergency Department RN and physician prior to contacting the covering psychiatrist. The BHS staff member initiates the phone call to the psychiatrist with a formal case review. ... 11. The attending psychiatrist on call is contacted on all patients after establishing medical clearance by the ER physician. ..."

Review of "Patient Assessment Protocol in the Emergency Department by RN," reviewed March 2013, revealed, "... 1. The primary assessment should be done on all patients who present to the Emergency Department regardless of presenting status. This includes: A. Assessment of airway and cardiovascular systems. This is done mainly by observation of respiratory effort, skin color, use of accessory muscles in respiration, level of consciousness, and vital signs. This assessment should be completed within one (1) minute. B. If the patient has a life-threatening problem, further assessment is delayed while intervention is implemented or assessment is conducted simultaneously as intervention is implemented. 2. A general survey including observation of mood, speech, thought organization, appearance, posture, ambulation status and odor can be done along with primary survey. 3. The patient history interview should focus on the chief complaint and those things past and present that are directly related to that complaint. It should include facts about the illness or injury: ... 4. Physical Examination - The nursing exam is performed briefly and rapidly. The Emergency nurse must be well versed in the normal findings and be able to interpret the abnormal findings quickly and accurately. ..."

Review of "Procedure for Initial Management of Patients with Acute Problems," reviewed March 2013, revealed, "... Definition: An approach for receiving the patient in the Emergency Department, including medical evaluation and physical assessment by qualified individuals. Appropriate service shall be rendered within the capability of the hospital, providing treatment of immediate needs or referrals to an appropriate facility as indicated. Purpose: 1. To admit the patient requiring emergency medical evaluation. 2. To provide nursing care in conjunction with therapeutic and diagnostic measures. 3. To collect data concerning patient condition. 4. To provide for immediate needs of the patient. 5. To provide emotional support to help relieve anxiety of patient and family/significant other. 6. Maintain provisions for patient safety. ..."

Review of "Emergency Department Rules and Regulations," reviewed March 2013, revealed, "... The following Rules and Regulations have been established by the Medical/Dental Staff as guidelines to facilitate quality care in an efficient manner, including appropriate follow-up care, in the Emergency Department. ... B. Emergency Physician Role and Responsibilities: 1. The Emergency physician on duty is responsible for evaluating all patients that seek care in the Emergency Department. All patients are to be given a medical screening exam, regardless of payer status, in compliance with EMTALA Legislation, that is directed toward identifying any or all emergency medical conditions that exist. If any emergency condition is identified, the patient must be stabilized within the capacity of this facility, including timely emergency specialty consultation for conditions or necessary procedures that exceed the ER's capabilities. ... The Emergency physician will adhere to standard of Care or Practice Guidelines established by Medical Staff specific for medical condition. They will be expected to have a working knowledge of EMTALA, and to maintain a professional demeanor and appearance at all times. ... E. Disposition of Patients: 1. Patient triage occurs upon arrival. The Emergency nurse and Emergency physician determine priority of needs. 2. Patients are to be examined by the physician according to medical urgency, not necessarily by time of arrival. ..."

Review of "Bylaws of the Medical/Dental Staff," revised March 2013, revealed, "... Article III: Staff Membership ... 3.3 Basic Responsibilities of the Staff Membership Each member of the staff shall: ... B. Abide by the medical/dental staff bylaws and rules and regulations, and by all other established standards, policies and rules of the hospital; ... ."

1. Review of an (EMS Provider) Trip Sheet dated August 19, 2013, revealed the ambulance crew arrived at the nursing home at 4:41 AM on August 19, 2013, to transport the patient. The report revealed, "... The patient's [family member] and the mental health delegate advised 'the patient would be transported to Jameson hospital for the psych evaluation and 302 commitment' ... (4:54 AM) transporting to Jameson hospital. ... (5:01 AM) ... arrived at Jameson hospital, the patient was removed from the back of the ambulance still secured onto the multi level stretcher, while walking toward the emergency room entrance, the crew was stopped from entering the emergency room by [EMP3-emergency room RN]. crew was advised by [EMP3] 'not to bring the patient into the emergency dept, that they were not going to take the patient' at that time [EMP3] told the crew to hold on and [EMP3] went into the emergency department and got the psych nurse who also came to the entrance door and stated 'the patient was not going to be seen there, they didn't have any open beds and that the crew would have to transport the patient to the [Other acute care facility] for the psych evaluation' I asked the psych nurse if the patient's [family member] was aware of the change [he/she] stated '[he/she] would advise [family member] of the change'... (5:06 AM) ... the patient was reloaded into the back of the ambulance for transport to [Other acute care facility] ... (5:27 AM) ... at [Other acute care facility] the patient was taken into the emergency dept ... patient report was given to RN [OTH12], [OTH12] was advised of the reason the patient was being brought into this facility and that the patient had originally been transported to Jameson and they refused the patient into their facility, [OTH12] documented all the info on a patient treatment sheet and assumed care of the patient from the crew at that time." The bottom of the form revealed the following, "Transportation Factors Affecting Care: Other: JMH [Jameson Memorial Hospital] refused patient access to emergency room."

2. On August 21, 2013, at 9:10 AM, EMP3 confirmed the ED physician was unaware of the patient being there (Jameson Hospital) and being diverted to (Other acute care facility) stating, "No. [ED physician] was not. At the time, we didn't think it was a situation." When asked to confirm that the patient was not seen by Jameson staff, made a Jameson patient or added to the ED log, EMP3 stated, "Correct."

3. On August 21, 2013, at 10:23 AM, when asked if ED employees know that once an ambulance arrives on the property, EMTALA applies, EMP2 stated, "Yes. They do."

On further interview, EMP2 confirmed that the patent was on hospital property. When asked if the patient should have been evaluated, EMP2 stated, "Absolutely."

4. On August 21, 2013, at 12:30 PM, when asked why the patient was not medically screened by the Jameson ED when the patient arrived there, OTH1 stated, "It was a decision the Jameson staff made."

5. When asked, at approximately 10:19 AM on August 22, 2013, what OTH6 recalled of the events surrounding the other facility's receipt of the patient, OTH6 stated, "... I got a call from [OTH1] asking for open beds. ... [OTH1] asked about what labs were required ... [OTH1] was supposed to fax me the information to call the doctor. ... I said, because we don't know if [the patient] will be medically cleared, have [patient] go to Jameson, and then they can send [patient] here [Ellwood City Hospital]. ... [OTH1] then called and said the patient was on the way to Jameson, and [the patient] was diverted. ...I asked where the paperwork was ... and OTH1 said [he/she] handed the paperwork to the ambulance [crew]. ... [OTH1] said [he/she] was going to fax the information from Jameson, but the ambulance crew was leaving [when he/she arrived at Jameson]. ..."

6. When asked, at approximately 11:00 AM on August 22, 2013, what OTH14 recalled of the events surrounding Jameson's refusal of access to the patient, OTH14 stated, "... We had parked ten to fifteen feet away from the hospital, where we take the patients in. ... We had the patient out of the ambulance, under the overhang, and [EMP3] stopped us ... and we had to load [patient] back up. ..."

7. When asked, at approximately 11:34 AM on August 22, 2013, what OTH12 recalled of the events surrounding Jameson's receipt of the patient, OTH12 stated, "... They [EMS crew] told me that they got called to [nursing home] ... to take a patient to Jameson. ... The patient wasn't combative ... and this RN [EMP3] said, 'You can't come in here.' ... [EMP3] disappeared and came back with who they introduced as a mental health delegate and said plans have changed. ... [The patient's] blood sugar was 400-something. ... Half hour later, [OTH2] gets a call from the county delegate ... and [he/she] said it was taken out of my hands. ..."

8. When asked, at approximately 1:27 PM on August 22, 2013, if OTH8 had received any communication from Jameson staff/physicians regarding the patient coming to the other facility, OTH8 stated, "... The patient was sent to Jameson. ... The squad [ambulance] was met by a nurse at Jameson and told to come to [other acute hospital] ED. ... There was no screening exam performed at Jameson. ..."

Based on review of facility documents and medical records (MR), and employee interviews (EMP), it was determined that the facility failed to ensure that a patient's medical screening examination and/or treatment was not delayed for one of 21 MR (MR1).

Findings include:

Review of "Emergency Department Rules and Regulations," reviewed March 2013, revealed, "... The following Rules and Regulations have been established by the Medical/Dental Staff as guidelines to facilitate quality care in an efficient manner, including appropriate follow-up care, in the Emergency Department. ... B. Emergency Physician Role and Responsibilities: 1. The Emergency physician on duty is responsible for evaluating all patients that seek care in the Emergency Department. ... The Emergency physician will adhere to standard of Care or Practice Guidelines established by Medical Staff specific for medical condition. They will be expected to have a working knowledge of EMTALA, and to maintain a professional demeanor and appearance at all times. ... E. Disposition of Patients: 1. Patient triage occurs upon arrival. ... Patients with emergency medical or traumatic conditions that exceed our facility's capabilities must be expeditiously transferred to an accepting facility capable of providing definitive care, in compliance with all the precept of EMTALA Legislation. All appropriate stabilizing measures available at our facility, including specialty consultation, must be instituted, assuming that they are not contraindicated due to any adverse effects of delaying transfer. These decisions will be made at the discretion and using the best judgment of the EP. ..."

Review of "Bylaws of the Medical/Dental Staff," revised March 2013, revealed, "... Article III: Staff Membership ... 3.3 Basic Responsibilities of the Staff Membership Each member of the staff shall: ... B. Abide by the medical/dental staff bylaws and rules and regulations, and by all other established standards, policies and rules of the hospital; ... ."

1. Review of an EMS Provider Trip Sheet dated August 19, 2013, revealed the ambulance crew arrived at the nursing home at 4:41 AM on August 19, 2013, to transport the patient. The report revealed, "... The patient's [family member] and the mental health delegate advised 'the patient would be transported to Jameson hospital for the psych evaluation and 302 commitment' ... (4:54 AM) transporting to Jameson hospital. ... (5:01 AM) ... arrived at Jameson hospital, the patient was removed from the back of the ambulance still secured onto the multi level stretcher, while walking toward the emergency room entrance, the crew was stopped from entering the emergency room by [EMP3-emergency room RN] crew was advised by [EMP3] 'not to bring the patient into the emergency dept, that they were not going to take the patient' at that time. [EMP3] told the crew to hold on and [he/she] went into the emergency department and got the psych nurse who also came to the entrance door and stated 'the patient was not going to be seen there, they didn't have any open beds and that the crew would have to transport the patient to the [Other acute care facility] for the psych evaluation' ... (5:06 AM) ... the patient was reloaded into the back of the ambulance for transport to [Other acute care facility] ... (5:27 AM) ... at [Other acute care facility] the patient was taken into the emergency dept ... patient report was given to RN [OTH12], ... was advised of the reason the patient was being brought into this facility and that the patient had originally been transported to Jameson and they refused the patient into their facility, ..." The bottom of the form revealed the following, "Transportation Factors Affecting Care: Other: jmh (Jameson Memorial Hospital) refused patient access to emergency room."

2. On August 21, 2013, at 9:10 AM, EMP3 confirmed the ED physician was unaware of the patient being there (Jameson Hospital) and being diverted to (Other acute care facility) stating, "No. [physician] was not. At the time, we didn't think it was a situation." When asked to confirm that the patient was not seen by Jameson staff, made a Jameson patient or added to the ED log, EMP3 stated, "Correct."

3. On August 21, 2013, at 10:23 AM when asked if ED employees know that once an ambulance arrives on the property EMTALA applies, EMP2 stated, "Yes. They do."

4. When asked, at approximately 11:00 AM on August 22, 2013, what OTH14 recalled of the events surrounding the other facility's receipt of the patient, OTH14 stated, "... We had parked ten to fifteen feet away from the hospital, where we take the patients in. ... We had the patient out of the ambulance, under the overhang, and [EMP3] stopped us ... and we had to load [patient] back up. ... We were initially told the patient would go to Jameson for a psych evaluation and then go to [other facility] for admission. ..."

5. When asked, at approximately 11:34 AM on August 22, 2013, what OTH12 recalled of the events surrounding the other facility's receipt of the patient, OTH12 stated, "... They [EMS crew] told me that they got called to [nursing home] ... to take a patient to Jameson. ... The patient wasn't combative ... and this RN [EMP3] said, 'You can't come in here.' ... [EMP3] disappeared and came back with who they introduced as a mental health delegate and said plans have changed. ... [The patient's] blood sugar was 400-something. ... Half hour later, [OTH2] gets a call from the county delegate ... and [he/she] said it was taken out of my hands. ..."

6. Review of the patient's medical record from the other facility revealed, "... Emergency Department - Physician Record ... Psych Disorder ... Date: 8/19/13 ... Chief Complaint: Psych Eval. ... Quality (current symptoms): ... agitated combative ... Disposition: admit psychiatric ... ." Further review revealed that the patient arrived and was triaged at 5:31 AM on August 19, 2013. Review of the "Emergency Department Nursing Assessment / Flow Sheet," revealed, "Chief Complaint Narrative: Pt was transported from ... Nursing Facility to Jameson Hospital ER for Psych eval and medical clearance. Upon arrival at the ER entrance, [ambulance] staff were approached by [EMP3] and advised that this patient was not to enter Jameson ER at this time and told to wait. After a couple of minutes [EMP3] returned with the county delegate. [ambulance] personal [sic] were then advised by the county delegate that [ambulance] were to take the pt to [other facility] ER for psych eval as there had been a change of plan and that the pts [family member] would be advised of such. ..."

Review of the patient's medical record revealed that the patient was discharged from the ED to the behavioral health unit at 8:17 AM. Upon discharge to the behavioral health unit, the patient had an IV infusing. Further review of the "Emergency Department Nursing Assessment / Flow Sheet," revealed that the patient was oriented to place and person, obeyed commands, was calm and cooperative. Further review revealed a nursing note at 5:45 AM stating, "pt straight cathed for UA C&S, pt noted to be grossly excoriated in perineal folds. ..." Additional nursing note revealed, "0603 [OTH1] phoned ED states "I just wanted to give you a heads up a patient from [nursing home] is coming to your facility" I stated pt and [family] had already arrived. I asked delegate if [he/she] was aware of procedure to transfer a pt between ER's and accepting physician. [OTH1] stated "it was taken out of my hands by the hospital they diverted [patient]." I explained that pt should of been medically cleared @ Jameson and that their MD should of spoken to our MD or psych Dr. [OTH2]" Review of the patient's medical record revealed that [patient] was admitted on a 201 commitment. Review of the patient's laboratory summary revealed that labs drawn at 6:01 AM on August 19, 2013, showed the following abnormal results: Sodium 134, Glucose 428, Creatinine 1.38, Total Protein 5.7, GFR 37.

Based on review of facility documents and medical records (MR), and employee interviews (EMP), it was determined that the facility failed to ensure appropriate transfers for one of one MR (MR1).

Findings include:

Review of Policy No.02.104, "BHS Emergency Department Assessment and Admission Procedure," reviewed/revised March 2013, revealed, "... 2.0 Directive ... Appropriate discharge disposition will be provided for those not admitted to BHS. ..."

Review of "Emergency Department Rules and Regulations," reviewed March 2013, revealed, "... The following Rules and Regulations have been established by the Medical/Dental Staff as guidelines to facilitate quality care in an efficient manner, including appropriate follow-up care, in the Emergency Department. ... B. Emergency Physician Role and Responsibilities: 1. The Emergency physician on duty is responsible for evaluating all patients that seek care in the Emergency Department. ... If there is an emergency condition that is identified, that exceeds this facility capability, all available stabilizing measures, again including specialist consultation, must be utilized, while simultaneously arranging expeditious transfer to another facility capable of providing end care to the patient. ... The Emergency physician will adhere to standard of Care or Practice Guidelines established by Medical Staff specific for medical condition. They will be expected to have a working knowledge of EMTALA, and to maintain a professional demeanor and appearance at all times. ... E. Disposition of Patients: ... 2. ... Patients with emergency medical or traumatic conditions that exceed our facility's capabilities must be expeditiously transferred to an accepting facility capable of providing definitive care, in compliance with all the precept of EMTALA Legislation. All appropriate stabilizing measures available at our facility, including specialty consultation, must be instituted, assuming that they are not contraindicated due to any adverse effects of delaying transfer. These decisions will be made at the discretion and using the best judgment of the EP. ..."

Review of the Scope of Care for the Emergency Department, revised March 2013, revealed, "... Plan for Emergency Care: ... 4. Provisions for transfer to another facility for treatment of those physical and/or emotional problems that require more specialized treatment than our hospital can provide include: A. Jameson's hospital-wide policy on transfer of patients denoting appropriate physician responsibility for contacting the physician to whom the patient is being transferred. ... B. Patients are not transferred until life saving measures are instituted and other emergency procedures are instituted that will minimize a compromise of the condition of the patient during transport. C. Arrangements for transfer to an appropriate center are made without regard to the patient's ability to pay for services or insurance status. ..."

Review of "Bylaws of the Medical/Dental Staff," revised March 2013, revealed, "... Article III: Staff Membership ... 3.3 Basic Responsibilities of the Staff Membership Each member of the staff shall: ... B. Abide by the medical/dental staff bylaws and rules and regulations, and by all other established standards, policies and rules of the hospital; ... ."

Review of "Rules and Regulations of the Medical/Dental Staff," revised March 2013, revealed, "... Preamble ... Each member's professional activities shall be conducted in accordance with the bylaws and related manuals of the Medical/Dental Staff, the rules and regulations of the Medical/Dental Staff, and the bylaws of the hospital, policies and procedures. ... I. Admission and Discharge of Patient ... B. Discharge/Discharge Planning ... 6. Transfer - A patient shall be transferred to another medical care facility upon the order of the attending physician, only after arrangements have been made for admission with the other facility, including its consent to receiving the patient, and only after the patient is sufficiently stabilized for transport. All pertinent medical information necessary to provide continuity of care shall accompany the patient ..."

Review of "Transfer of Acute Patient to Another Acute Care Facility," no policy number provided, reviewed December 2012, revealed, "... Supportive Data: Provides a process for transfer of the patient to another level of care/health professional as indicated. Level of caregiver is based on the patient=s assessed needs and the facilities capacity to provide the needed care/treatment. ... Steps 1. Appropriate physician to discuss transfer with patient/significant other, identifying potential risks/benefits involved. ... 3. Obtain appropriate consents: A. #140 Physician Certification For Transfer. ... A. Parts 1 & 2 must be completed by transferring physician. ... 4. Initial arrangements must be made by the referring physician/designate: A. Arrange transfer by contacting receiving physician. B. Physician should order appropriate transfer mode and personnel. ... 6. Unit/department staff must confirm arrangements with receiving hospital by contacting receiving facility/appropriate staff. A. Nursing should provide nursing report to admitting unit/department. ..."

1. Review of an (EMS Provider) Trip Sheet dated August 19, 2013, revealed the ambulance crew arrived at the nursing home at 4:41 AM on August 19, 2013, to transport the patient. The report revealed, "... The patient's [family member] and the mental health delegate advised 'the patient would be transported to jameson hospital for the psych evaluation and 302 commitment' ... (4:54 AM) transporting to jameson hospital. ... (5:01 AM) ... arrived at jameson hospital, the patient was removed from the back of the ambulance still secured onto the multi level stretcher, while walking toward the emergency room entrance, the crew was stopped from entering the emergency room by [EMP3] {emergency room RN} crew was advised by [EMP3] 'not to bring the patient into the emergency dept, that they were not going to take the patient' at that time [EMP3] told the crew to hold on and [EMP3] went into the emergency department and got the psych nurse who also came to the entrance door and stated 'the patient was not going to be seen there, they didn't have any open beds and that the crew would have to transport the patient to the [Other acute care facility] for the psych evaluation' ... (5:06 AM) ... the patient was reloaded into the back of the ambulance for transport to [Other acute care facility] ... (5:27 AM) ... at [Other acute care facility] the patient was taken into the emergency dept ... patient report was given to RN [OTH12], ... was advised of the reason the patient was being brought into this facility and that the patient had originally been transported to jameson and they refused the patient into their facility, [OTH12] documented all the info on a patient treatment sheet and assumed care of the patient from the crew at that time." The bottom of the form revealed the following, "Transportation Factors Affecting Care: Other: jmh (Jameson Memorial Hospital) refused patient access to emergency room."

2. On August 21, 2013, at 9:10 AM, EMP3 confirmed the ED physician was unaware of the patient being there (Jameson Hospital) and being diverted to (Other acute care facility) stating, "No. [He/She] was not. At the time, we didn't think it was a situation." When asked to confirm that the patient was not seen by Jameson staff, made a Jameson patient or added to the ED log, EMP3 stated, "Correct."

3. On August 21, 2013, at 10:23 AM, when asked if ED employees know that once an ambulance arrives on the property EMTALA applies, EMP2 stated, "Yes. They do."
Further interview with EMP2 confirmed that the patient was on hospital property.

4. On August 21, 2013, at 10:34 AM, when asked about interactions with the patient's [family member] while at Jameson, EMP5 stated, "[OTH1] walked out with me to talk with the [family member]. ... I said that I was concerned that [family member] would come here and then have to go to [Other acute care facility] ... went back in and spoke with [OTH7- EMS dispatcher] ... called [Other acute care facility]. I thought I'd give them a heads-up." At 10:38 AM, when asked if EMP5 was aware that the patient had arrived at the Jameson ED while talking to the [family member], EMP5 stated, "Yes." At 10:39 AM, when asked the [family member's] response to the change of being medically cleared at [Other acute care facility] and not at Jameson, EMP5 stated, "[He/She] seemed OK. I wanted to be sure that [he/she] was aware of the arrangements. ... I thought it was like a direct admission."

5. On August 21, 2013, at 12:25 PM, a telephone conference call interview was conducted with OTH1 and OTH10. OTH1 stated that the plan was to get medical clearance at the Jameson ED and then transfer the patient to [Other acute care facility] for a behavioral health admission. When asked to confirm that the reason the patient was being sent to Jameson for medical screening rather than directly to the other acute care facility for the medical screening and admission was because OTH1 had another assessment to perform at Jameson ED, OTH1 hesitated, then responded, "Yes."

On further interview, when asked why the patient was not medically screened by the Jameson ED when the patient arrived there, OTH1 stated, "It was a decision the Jameson staff made." OTH1 added that he/she later called the receiving ED and confirmed that the patient was all right and the needed testing would be done.

6. When asked, at approximately 10:12 AM on August 22, 2013, what OTH2 recalled of the events surrounding the other facility's receipt of the patient, OTH2 stated, "... I had gotten a call from, I assume, a nurse, [EMP5]; ... and said that [he/she] had spoken with someone ... from our Behavioral Health, and that the patient was accepted to our behavioral health. ... So I called our behavioral health ... and they said they had said there was a bed available, but had not accepted the patient [for admission]. ... EMS was told to reroute to us [other facility]. ... The mental health delegate then contacted us and said they were giving us a heads up [that the patient was coming], and I said ... aren't you familiar with how to transfer patients between ER's? ... [He/She] said it was taken out of [his/her] hands by Jameson staff. ..."

7. When asked, at approximately 10:19 AM on August 22, 2013, what OTH6 recalled of the events surrounding the other facility's receipt of the patient, OTH6 stated, "... I got a call from [OTH1] asking for open beds. ... I told [him/her] we did [have open beds] as long as it was geriatric. ..." OTH6 then stated that he/she was informed that the patient was in a nursing home in New Castle. OTH6 continued, "I said, 'Did you know Jameson has geriatric [behavioral health]?' ... [OTH1] said they [Jameson] said they were full. ... [OTH1] asked about what labs were required ... [OTH1] was supposed to fax me the information to call the doctor. ... I said because we don't know if [the patient] will be medically cleared, have [patient] go to Jameson, and then they can send [patient] here. ... [OTH1] then called and said [the patient] was on [his/her] way to Jameson, and then was diverted. ... I asked where the paperwork was ... and [OTH1] said [he/she] handed the paperwork to the ambulance [crew]. ... [OTH1] said [he/she] was going to fax the information from Jameson, but the ambulance crew was leaving [when he/she arrived at Jameson]. ..."

8. When asked, at approximately 11:00 AM on August 22, 2013, what OTH14 recalled of the events surrounding the other facility's receipt of the patient, OTH14 stated, "... We had parked ten to fifteen feet away from the hospital, where we take the patients in. ... We had the patient out of the ambulance, under the overhang, and [EMP3] stopped us ... and we had to load [patient] back up. ... The mental health delegate was at [nursing home] with the ... POA. [He/She] gave us paperwork at [nursing home]. ... We were initially told the patient would go to Jameson for a psych evaluation and then go to [other facility] for admission. ..."

9. When asked, at approximately 11:34 AM on August 22, 2013, what OTH12 recalled of the events surrounding the other facility's receipt of the patient, OTH12 stated, "... Before the patient came in, we got a call ... from [EMP5], from Jameson Hospital. ... [EMP5] said you're going to get a patient, [he's/she's] going to your BHU [behavioral health unit]. ... [OTH2] called our BHU, ... and our BHU said they had not accepted the patient [for admission]. ... They [EMS crew] told me that they got called to [nursing home] ... to take a patient to Jameson. ... The patient wasn't combative ... and this RN [EMP3 - Jameson] said, 'You can't come in here.' ... [EMP3] disappeared and came back with who they introduced as a mental health delegate and said plans have changed. ... [The patient's] blood sugar was 400-something. ... Half hour later, [OTH2] gets a call from the county delegate ... and [he/she] said it was taken out of my hands. ..."

10. When asked, at approximately 1:27 PM on August 22, 2013, if OTH8 had received any communication from Jameson staff/physicians regarding the patient coming to the other facility, OTH8 stated, "... The patient was sent to Jameson. ... The squad [ambulance] was met by a nurse at Jameson and told to come to [other facility] ED. ... There was no screening exam performed at Jameson. ... There was no call from a physician at Jameson [to the other facility]. ..."