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Based on observation, interview, and document review, the hospital failed to ensure compliance with requirements at 42 CFR 489.24 as evidenced by the deficient practice cited at 42 CFR 489.24(a) and 489.24(c).

Based on document review and interview, the hospital failed to maintain a central log for every individual that came into the emergency department (ED) for treatment for 1 of 21 (P1) patients who presented to the ED.

Findings include:

Review of P1's Pre-hospital Care Report (ambulance report) dated 9/22/2016, at 8:45 p.m. revealed an advanced life support (ALS) ambulance responded and arrived at P1's home to take over the care of P1 from a basic life support (BLS) ambulance. Upon arrival, P1 had no pulse or respirations, had an airway established and was on a LUCAS chest compression system that provided chest compressions for the patient. The automated external defibrillator (AED) had advised no shock prior to the arrival of the ALS paramedics. ALS paramedics placed an intraosseous (I/O) or infusion directly into the bone marrow and provided medications to P1 according to protocol. P1's return of spontaneous circulation (ROSC) occurred seven minutes after the arrival of the ALS paramedics. ALS requested helicopter transport of P1 with the meeting location to take over the care and transportation of P1 at the hospital. During the transport of P1 to the hospital (7 miles from the patient's home), the ambulance crew was notified the original helicopter from comming from Hibbing (approximately 24 miles from the hospital) was grounded. Another helicopter from Minneapolis (198 miles away from the hospital) would take over the patient's transportation and care at the hospital in approximately sixty-five minutes. At approximately 9:40 p.m., the ALS ambulance arrived at the hospital and directed to the trauma bay in the ED. At that time, P1 was on a mask for artificial respirations and the paramedics had given P1 medications for sedation and paralysis. The paramedics informed the physician (MD)-B the helicopter transport would be approximately sixty-five minutes until arrival to the hospital. At that time, MD-B told the paramedics to transport P1 to a Duluth hospital about one hour from this hospital ED. The ALS paramedics took P1 back to the ambulance and began transporting the patient to a second hospital. When the ambulance was approximately ten minutes away from this hospital, the ALS paramedics received an direction from this hospital to return P1 back to this hospital.

Review of the hospital's central log for the ED revealed there was no documentation of P1's first arrival to the ED on 9/22/2016 at 9:40 pm. The only entry for P1 in the ED log established P1 entered the ED on 9/22/2016, at 10:17 p.m. the return back to the hospital with the chief complaint of loss of consciousness and a diagnoses of cardiopulmonary arrest.

Interview with the RN Manager on 10/6/2016, at 1:15 p.m. established when P1 was initially brought into the ED by the ALS paramedics, P1 should have been entered into the ED's central log.

Review of the hospital's policy and procedure titled Emergency Department Triage with an approval date of 2/2016, stated, "A log entry should be made at the first point of contact." The log must contain the name of the individual seeking assistance, whether the individual refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, or was discharged.

Based on documentation review and interview, the hospital failed to ensure that each patient who presented to the emergency department (ED) received an appropriate medical screening examination for 1 of 21 (P21) patients reviewed. The hospital's failure to complete a medical screening exam posed an immediate threat to P1's health and safety and has the potential to effect all patients that presented to the ED with an emergency medical condition.

Findings include:

Review of P1's Pre-hospital Care Report (ambulance report) dated 9/22/2016, at 8:45 p.m. revealed an advanced life support (ALS) ambulance responded and arrived at P1's home to take over care of P1 and provide transportation from a basic life support (BLS) ambulance. Upon arrival, P1 had no pulse or respirations, had an airway established, and was on a LUCAS chest compression system that provided chest compressions for the patient. The automated external defibrillator (AED) had advised no shock prior to the arrival of the ALS paramedics. ALS placed an intraosseous (I/O) or infusion directly into P1's bone marrow and provided medications to P1 according to protocol. P1 had a return of spontaneous circulation (ROSC) within seven minutes after the arrival of the ALS paramedics. ALS paramedics requested helicopter transport of P1 with the meeting location at this hospital. The helipad was located on the roof of the hospital with entrance through the ED. During the ambulance transport of P1 to the hospital (7 miles from the patient's home), the paramedics were notified the original helicopter coming from Hibbing (24 miles from the hospital) was grounded. Another helicopter from Minneapolis (198 miles from the hospital) would land at the hospital in approximately sixty-five minutes. At approximately 9:40 p.m., the ALS ambulance arrived at the hospital and the paramedics were directed to the trauma bay in the ED. P1 was on a bag mask for artificial respirations and the paramedics had given P1 medications for sedation and paralysis. At 9:40 p.m., P1's vital signs included a blood pressure (BP) 138/79, pulse 60, oxygen saturation 98% with a high oxygen flow, and no spontaneous respirations. The paramedics informed the physician (MD)-B the helicopter transport would be approximately sixty-five minutes until arrival to the hospital. At that time, MD-B told the paramedics to transport P1 to another hospital (not specified) in Duluth 65 miles from this ED. Around 9:53 p.m. the paramedics took P1 back to the ambulance and began transporting P1 to a second hospital. At that time, P1's vital signs taken by the paramedics were a BP of 156/95, pulse 85, respirations of 12 through the artificial airway and mask, and an oxygen saturation of 97% on a high oxygen concentration. MD-B had not designated one of two hospital's in Duluth therefore the paramedics decided on a hospital and called the hospital staff with a report and an estimated time of arrival (ETA). When the ambulance was approximately ten minutes away from the first hospital, the ALS paramedics were contacted by their Chief to return to the first hospital's ED. MD-B ordered the ambulance to return P1 to the first hospital's ED. Prior to arriving to the first hospital's ED, at 10:04 p.m. P1 lost his pulse and ALS paramedics started the LUCAS device for chest compressions. After one dose of epinephrine P1 had a return of spontaneous circulation. At 10:10 p.m., and again prior to the second arrival at the first hospital, P1 lost his pulse a second time and required LUCAS chest compressions and one dose of epinephrine with a return of circulation. The ALS paramedics arrived the second time at hospital #1's ED around 10:22 p.m. or forty-two minutes after first arriving at the hospital. P1's vital signs at that time were a BP 148/116, pulse 88, artificial respirations of 12, and oxygen saturation at 96% on a high flow of oxygen.

There was no ED documentation of P1's first arrival by ambulance on 9/22/2016, to the ED or evidence of a MSE completed by MD-B.

Review of P1's ED medical record dated 9/22/2016, at 10:20 p.m. (time varies from the ambulance report) indicated P1 was roomed in the ED trauma bay with MD-B's first contact at 10:23 p.m. when the MSE was initiated. At 10:33 p.m. P1 went into cardiac arrest. ACLS protocol was followed and included providing P1 with an epinephrine intravenous drip and IV push doses, additional emergency medications such as Dopamine to maintain a blood pressure, artificial respirations with a ventilator, chest compressions with the LUCAS, EKG's, chest x-ray, and lab. P1 remained in asystole or without heart contractions, not responding to the protocol and expired at 11:27 p.m.

Interview with paramedic (PM)-A on 10/5/2016, at 5:06 p.m. established he responded to a request to provide care for and transportation to P1 by the BLS ambulance. PM-A indicated he and another paramedic arrived at P1's home exact time not known and began assisting the BLS crew. P1 did not have a pulse or respirations but had an airway being provided respirations with a mask and a LUCAS device that was providing chest compressions. The ALS paramedics placed an intraosseous (I/O) or infusion directly into P1's bone marrow and gave epinephrine. P1 responded with a return of circulation. P1 had been without a pulse for seven minutes. PM-A arranged for a helicopter to meet and transport P1 at the hospital's helipad. The first helicopter scheduled to leave from Hibbing was not able to fly. A second helicopter from Minneapolis was scheduled with an approximate ETA at the hospital helipad in sixty-five minutes. P1 was being ventilated with an artificial airway and mask. Once in the hospital's ED, exact time not known, the paramedics brought P1 into the trauma bay where MD-B and one or two nurses were waiting for P1. PM-A began providing a report to MD-B and indicated the helicopter was at least an hour away and ground transfer may be quicker. The paramedics prepared to transfer P1 to the ED's gurney when MD-B stopped them. MD-B told the paramedics to load P1 back into the ambulance and take P1 to a hospital in Duluth. PM-A said P1 was in the ED for a few minutes. After leaving the ED, PM-A placed P1 on a ventilator and the paramedics had to decide which hospital to transport P1 to. Report was provided to that hospital. After approximately fifteen minutes (exact amount of time not known) on the road, the paramedic received a call from his Chief directing the ambulance back to the first hospital's ED. PM-A contacted MD-B for clarification and was told to return with P1. MD-B said he thought the ambulance had made the arrangements with a receiving hospital prior to P1's initial visit to the ED. On the return trip to the hospital's ED, P1 went into cardiac arrest two times with a return of circulation each time with a dose of epinephrine.

Interview with MD-B on 10/6/2016, at 7:30 a.m. revealed when P1 initially presented by ambulance to the ED MD-B thought ground transport would be quicker. MD-B thought the paramedics had arranged a receiving hospital in Duluth for P1. MD-B said he did not complete a MSE for P1 during P1's initial encounter in the ED. After the ambulance left the hospital, RN-C told MD-B a hospital in Duluth had contacted the ED and said MD-B was in violation of EMTALA by not providing P1 with a MSE. At that time, MD-B ordered the ambulance to return to the ED to avoid an EMTALA violation.

Interview with RN-C on 10/6/2016, at 8:50 a.m. revealed she was the hospital's` supervisor the evening of 9/22/2016, when P1 presented to the ED. RN-C was contacted by the helicopter crew exact time unknown but prior to P1's initial encounter in the ED, informing the hospital their ETA was approximately fifty-five minutes. Upon arrival to the ED, P1 had a pulse and was intubated. RN-C and another ED RN directed the paramedics to the trauma room. P1 was in the ED for only a few minutes when MD-B decided ground transportation would be quicker for P1. MD-B did not complete a MSE for P1 prior to P1 leaving the ED. After the ambulance left with P1, RN-C canceled the helicopter. RN-C said she was not aware of a specific hospital in Duluth arranged to accept P1. After an undetermined amount of time, the ED received a call from a hospital in Duluth informing staff of an EMTALA violation for not providing P1 with a MSE. RN-C informed MD-B of the call and MD-B decided to have the ambulance return to the hospital's ED for P1's MSE. RN-C contacted the ambulance Chief who contacted the ambulance crew to have them return to this hospital's ED.

Review of the Documentation of Death certificate for P1 revealed the immediate cause of death was severe pulmonary hypertension and pulmonary fibrosis at 11:27 a.m. on 9/22/2016.

Review of the hospital's EMTALA policy and procedure with an approval date of 2/2016, stated when an individual presented to an ED requesting examination for a medical condition or a request was made on behalf of the individual, the hospital would through a qualified medical professional provide an appropriate MSE to determine whether or not an emergency condition existed. An emergency medical condition was defined as acute symptoms such that without immediate medical attention the person's health may be placed in immediate jeopardy or there may be serious impairment to bodily functions or serious dysfunction to any bodily organ or part.