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Based on findings from medical record review, interview, and document review, the hospital failed to comply with the requirements at 489.24(a) and related requirements at 489.24(c).

Please reference findings at Tag 2406.

Based on findings from medical record (MR) review, interview, and document review, in 1 of 20 (Patient #1) MRs reviewed, the hospital failed to provide an appropriate medical screening exam, stabilizing treatment and appropriate transfer. This could lead to untoward patient outcomes.

Findings include:

-- Per MR review, Patient #1, a 56-year-old female, presented to the emergency department (ED) on 9/7/17 at 11:27 pm via emergency medical services from the hospital's nursing home (ECF). The patient was triaged at 11:35 pm as a level 2 on the Emergency Severity Index (1 = most urgent, 5 = least urgent). Nursing documented the chief complaint as neurological deficit and the stated reason for the visit was possible stroke. Patient was unresponsive.

Staff A, ED physician documented the following on 9/8/17 at 6:54 am. (Patient #1 was initially seen on 9/7/17 at 11:48 pm.) The patient was brought from the ECF with possible stroke symptoms. ECF called 911 when they realized the patient was unresponsive. The last time Patient #1 was normal was approximately 1 hour prior to arrival to the hospital's ED. Instructions given to emergency medical services were to take the patient to Hospital A but there was some kind of misunderstanding. When the patient arrived in Oneida Hospital's ED, the clerk called the ECF who told him/her the patient was not supposed to be at Oneida Hospital. Emergency medical services crew seemed confused and claimed they were not told the patient was going to a different facility. Emergency medical services spoke to their manager who said the patient could not be loaded back into the ambulance. Administrator in house was contacted who was not sure how to resolve issue. At that time the patient had been in Oneida Hospital's ED for approximately 15 minutes and I decided to initiate stroke workup, CT (computed tomography) head and labs were ordered. Before the tests could be performed the emergency medical services manager called back to say they would transfer the patient to Hospital A after all, due to the fact that the patient was potentially having an acute stroke and was supposed to go to a stroke hospital in the first place. The workup was cancelled and another emergency medical services crew arrived to take the patient to Hospital A for possible acute stroke. At the time it was unclear if this would be considered an EMTALA violation, but since the patient was already 1.5 hours into a possible acute stroke we did not want to do anything else that might prevent her from getting an intervention. On 9/13/17 at 12:03 am, Staff A documented "Addendum to Original Note." "To clarify earlier note, once the decision to keep the patient was made I did do a brief exam of the patient, I inspected her, saw that she was not in any acute distress, had a normal respiratory rate and had a normal saturation on room air. I attempted to speak to the patient but she was unresponsive to verbal stimuli with her eyes shut and not moving. I noted that her face was symmetrical. I checked her pupils and noted they were reactive to light and equal in size but she was unable to cooperate with an EO (eye) exam. Patient was warm to touch with good color, not diaphoretic, had no obvious trauma or injury, was not shaking or convulsing. Once decision was made to transfer the patient I again reassessed her in the room to check that her condition had not changed and that her vital signs were still stable."

Staff B, ED Registered Nurse, documented on 9/8/17 at 8:02 am, "Patient here from ECF... ECF called 911 for stroke. Patient was supposed to go to (Hospital A) per ECF supervisor ... EMS (emergency medical services) did not hear that. Patient was here for 40 minutes then EMS took patient to (Hospital A). (Medical record did not indicate date and time patient was transferred to Hospital A.)

-- Per interview of Staff A (provided care to Patient #1) on 9/19/17 at 8:45 am, Patient #1 arrived by ambulance without prior notification from the ECF. Patients from the ECF are usually transported through the tunnel that connects the hospital to the ECF. The ECF was contacted and the hospital was told it was a mistake that Patient #1 was brought to them, she was supposed to go to Hospital A. Staff B was not sure if the ECF was part of the hospital since they are connected and not sure if it would be an EMTALA (Emergency Medical Treatment and Labor Act) violation if they sent Patient #1 to Hospital A (as had been ordered by her physician.) Staff B was checking with the nursing supervisor while emergency medical services was talking to their supervisor. The nursing supervisor didn't know what to do and was asked to call the administrator on call. (This did not occur.) Emergency medical services was told by their supervisor that they could not take the patient back. Staff A then ordered a head CT and inspected the patient. Staff A recalls Patient #1 was not moving and was not responsive. He/she was aware the patient had a history of seizures and bleeding stroke. It had been 1 hour and 20-30 minutes since Patient #1 had last been seen at her baseline. At this time emergency medical services called back and said they would take the patient to Hospital A. Staff A was unsure if this was an EMTALA violation, however, emergency medical services was willing to take Patient #1 and he/she sent the patient as she was still in the window of stroke protocol. The patient was on a monitor, vital signs were good, pupils were checked and looked equal. Staff A did not listen to Patient #1's heart and lungs, the patient appeared stable. He/she did not examine Patient #1 for the legal purpose of EMTALA, the patient was examined to make sure she was stable.

-- Per review of the hospital's policy and procedure (P&P) titled "Emergency Medical Treatment & Active Labor Act (EMTALA)," last reviewed 7/2016, "it is the intent of the hospital to assure that when an individual comes to the Emergency Department (ED), Labor and Delivery or elsewhere on the hospital's campus with an apparent or actual Emergency Medical Condition (EMC), that individual will receive an appropriate MSE (medical screening exam) and stabilization specific to the individual's condition and to the extent of the hospital's capability. The MSE is the initial and on-going evaluation of the presenting patient conducted by a physician or physician extender ... including history, physical examination, appropriate testing, completion of appropriate documentation and evaluation of the patient within the capabilities of this hospital utilizing those facilities routinely available to the ED, including the use of indicated on-call physicians as appropriate, to determine whether a patient has an EMC as defined by law and/or to ensure that the patient does not have an EMC as defined by law. If the patient is determined to have an EMC, necessary stabilizing treatment within the capabilities of the medical staff and the facility, including those ancillary services that are routinely available to the ED will be administered. Transfer of a patient from the hospital after medical treatment within its capacity and capability that minimizes the risks of the individuals health ... the hospital has confirmed in advance that the receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept transfer of the individual and to provide appropriate medical treatment. The hospital sends the receiving facility copies of all medical records related to the emergency condition that are available at the time of transfer, results of diagnostic studies, results of tests ... . The referring physician shall order the provision of appropriate transport, equipment, personnel and therapeutic intervention required for transfer. This is a joint decision between the referring and receiving physician. A nurse to nurse report is mandatory between transferring and receiving facilities."

Patient #1 did not receive an appropiate medical screening exam or any stabilizing treatment. An appropriate transfer was not arranged. Hospital A was not notified of transfer. No transfer paperwork was sent with the patient.