HospitalInspections.org

Based on observations, interviews and document review, it was determined that the facility staff failed to maintain a complete central log of all the patients who came to the ED seeking care for an EMC. There was no evidence that three (3) of the patients (#21, #23 and 25) were registered by the facility and a medical record for the requested date of service could not be located. One (1) patient, #24, had documentation (from the EMS run sheet) that they were "registered" by the facility staff; however, a medical record for the date of service was not located.

The findings included:

The surveyors reviewed emergency medical service (EMS) "run sheets" for twenty-eight (28) patients who were brought to the facility by ambulance. The surveyors conducted medical record reviews on 9/13/22 at 9:46 a.m. and again on 9/14/22 at 12:10 p.m. for the twenty-eight (28) patients with assistance from staff member #8, staff member #9 and staff member #10. During the review process and using the information provided on the EMS "run sheet", the surveyors requested to see the medical record for patient #21, patient #23, patient #24 and patient #25. The staff members (#8, #9 and #10) were unable to locate a medical record in the electronic medical record (EMR) for the four (4) patients requested (21, 23, 24 and 25).

A review of the EMS "run sheet" documented the following on patient #21: EMS arrived at the facility on 7/6/22 at 8:06 p.m.; at 9:19 p.m. the patient was "transferred" to Fairfax. The EMS note reads, in part: " ...Upon arrival of ED there was no ETA in entrance to ED. After a 30 minute wait with no direction and given no ETA from RN Charge and Med Control. Dr. Yang and BC notification, patient agreed to be transported to Fairfax ED. Fairfax was notified en route ...".

A review of the EMS "run sheet" documented the following on patient #23: EMS arrived at the facility on 1/4/22 at 5:42 p.m.; at 9:40 p.m. EMS was inside the facility. The EMS note reads, in part: "Upon arrival at the hospital we began a lengthy wait to transfer care. During the lengthy wait time, the patient began to remember things and answer all the questions appropriately. After several hours of waiting, the OMD spoke with hospital management and we were told to bring the pt in for eval. We moved the pt to triage and awaited an assessment with the triage RN. Once moved into triage, report was given to RN and transfer of care began. Registration had not registered the patient yet, when he decided to leave because his Uber arrived. RN signed for pt transfer but no Hospital record number was created. After 3 hours and 37 minutes of waiting the pt decided to leave the ER and Uber home."

A review of the EMS "run sheet" documented the following on patient #24: EMS arrived at the facility on 1/1/22 at 8:10 p.m. and a "dest transfer" occurred at 9:19 p.m. The EMS note reads, in part: "Once in ambulance bay at Sentara, PT unstrapped and assisted into position of comfort ...driver reports unknown eta for room availability, and went to get a wheelchair for the PT so that he could sit more comfortably and be off our stretcher since he was so uncomfortable on it ... PT positioned near back door/ ambulance entrance door of ER to await room availability/assignment. After a 20 minute or so wait, the PT stated that he needed to use the restroom again. The charge nurse would not allow PT into the ER until a room was available, so a bedside commode was requested for the PT to be able to relieve himself. Charge nurse denied multiple requests for a bedside commode and the PT ended up urinated on himself/ the wheelchair/ the ground near the back entrance of the ER before a urinal could be procured. Charge nurse notified, and still refused toilet access / portable toilet. After waiting approximately 10 more minutes, the PT was getting uncomfortable due to dropping temperatures and light drizzle. PT also stated that he was going to need to use the restroom again soon. PT wheeled using wheelchair to the front entrance of the ER, and was registered. During the wait for the triage nurse, the PT became increasingly agitated due to the wait ... PT eventually asked to wait outside so he could have his mask down until the triage nurse was ready for him. PT wheeled back outside the ER entrance, to await triage ... PT becoming more and more upset with the wait time and overall situation, and multiple attempts were made to notify ER staff of the overall situation ... driver checked with charge nurse again on room assignment / wait time and told that since we brought him inside the front of the ER for registration and to use the restroom, he was going to have to wait his turn there and she would no longer allow him to be given a room assignment as an EMS transport PT, and would not assist us or the PT further. After additional waiting, the triage nurse attempted to get the PT inside to be triaged, but the PT continued to refuse care at that time ... Triage nurse then signed PPCR, assuming PT care. States that after each PT she will go outside to check on the PT ... PT left as his direction outside the front / main entrance to ER, after both he and daughter, were consulted to ensure nothing further could be done for PT by [EMS]".

A review of the EMS "run sheet" documented the following on patient #25: The EMS note reads, in part: "Patient transported priority 2 to SENTARA ... Arrived at SENTARA at 0025, was instructed to hold in ED bay until bed becomes available. After 45 minutes of waiting, ... OIC enacted OMD Directive 13.5.4.4. patient was explained that there was an extended wait without an estimate on when she could be accepted. Patient was further explained that EMS was allowed to offer her a transport to an alternative facility but that we would wait of that was her preference. Patient stated that she would accept transport and just wants to go to the closest facility. Inova Fairfax determined most appropriate due to potential for hospital admission. OLMC is contacted at Sentara, Dr Graber is explained situation and directive from EMS OMD and that due to extended wait the patient has accepted offer to transport to another facility. After brief hold Dr Graber acknowledges that there is still no bed available for patient and understands EMS OMD has authorized this. PSCC advised of new transport ...".

Based on observations, interviews and document review, it was determined that the facility staff failed to register patients upon arrival to the emergency department (ED) and appropriately triage and prioritize patients for further evaluation by a qualified medical personnel (QMP) based upon the patient's presenting signs/symptoms. The documentation evidenced that twenty-four (24) patients were held in a parked ambulance on hospital property for various amounts of time, ranging from thirty (30) minutes to three (3) hours, before the facility "accepted" the patients and began the registration and triage process. Delays in registration and triage contribute to delayed completion of the medical screening examination (MSE) to rule out an emergency medical condition (EMC), which has the potential to negatively impact patient outcomes.

The findings include:

In the afternoon of 9/12/2022, the surveyors conducted a tour and observations of the emergency department (ED). The ED has thirty-seven (37) beds and SM #6 said "on average we can staff twenty-nine [29] beds". During the tour, the surveyors reviewed the process of patients who arrive to the ED by a personal vehicle (i.e. not by an emergency transport) with Staff Member (SM) #6. SM #6 explained that upon entry into the ED, the patient "registers at the desk" is then triaged "if they can stop there" or would go "directly to a bed if one is available". If there is no bed available and the patient requires "eyes on them", the patient would be directed to sit in the "advance care chairs" (approximately six chairs located adjacent from the nursing station) so they are "visible from the nurse's station". If a patient is triaged, there are no available beds, and their emergency severity index (ESI) level indicates a lower level urgency, the patient will be directed back to the lobby to wait. (The ESI level is a tool used by staff to determine the level of urgency and resources needed to care for the patient's complaint and/or condition. The level ranges from 1 to 5; with one (1) being the highest urgency (the patient's condition is emergent, possibly life-threatening) and a five (5) being the lowest level of urgency.)

The process for patients arriving by emergency medical service (EMS) was reviewed. SM #6 explained that the facility receives a pre-notification (the EMS unit calls in) that "they are coming". The EMS call is taken by either the charge nurse, another ED nurse, or a senior ED technician. The information obtained includes, but is not limited to, the EMS unit number calling in, the age and gender of the patient, vital signs, if there is an intravenous (IV) access site established, a blood glucose reading, the chief complaint and if any medications have been given. If the charge nurse is not the one to take the call, the information will be written down on a form and given to the charge nurse. From there, the charge nurse will begin to work on a bed assignment for the incoming patient. Once the EMS unit arrives, the patient remains outside in the ambulance and a "medic will usually come inside". There a number of scenarios that can occur: EMS will be instructed to bring the patient inside and go to triage, the patient will go directly to a bed, EMS will be instructed to bring the patient inside and wait in a hallway space, or EMS will be instructed to remain outside until notified by the staff to come in. When EMS is instructed to remain outside until notified to come in, "EMS monitors the patient"; no one from the ED staff goes outside to perform an assessment.

SM #6 explained that patients are "held outside" only when "absolutely necessary". SM #6 said that having EMS wait outside is not a standard of practice for the facility, but one that occurs out of "necessity". SM #6 said the patients are not registered while they are waiting outside. The registration and triage, which includes determining the patient's ESI level, occurs once the patient is inside and a "transfer of care" has occurred. The surveyors requested clarification regarding "transfer of care"; SM #6 said "we want the medics to talk to the nurse who is receiving the patient to give the report". The surveyors inquired about the ED staff performing an initial triage upon the arrival of the patient. SM #6 noted that the staff do a "triple triage" of the patient; once on the phone when EMS calls with a brief description of the patient and chief complaint, again when EMS arrives and the "medic" comes in; a nurse will ask about the status of the patient, and lastly when EMS physically brings the patient into the facility and the nurse "puts eyes" on the patient to see if what has been reported "is accurate". SM #6 explained that even if the ED is full, when EMS arrives and a patient is "critical" or the patient's condition has deteriorated, "we will get them inside to a room".

The surveyors requested to view a written policy or procedure regarding the transfer of care. SM #6 reported that the facility did not have anything in writing, but the "Regional EMS of Northern Virginia" defines it as when the patient is "off the stretcher and report has been given". Additionally, the surveyors requested to review the policy and/or procedure regarding the process for the following: receiving EMS calls, receiving incoming patients via EMS, and receiving patients who arrived to the ED by a personal route. The facility did not have any written policies and/or procedures to provide for these processes.

In the afternoon of 09/12/22, the surveyors received the EMS "Patient Care Manual" (with last revision date of 04/01/22) for the county in which the facility is located. Under the "Preliminary Information: Transfer of Care at Hospitals" header on page "XIII", the manual reads, "Once on hospital property, the receiving facility assumes responsibility for all further medical care delivered to patients transported by EMS".

On 09/12/22 at 3:18 p.m., an interview was conducted with Staff Member #6 (Director of Emergency Services). The surveyor addressed the aforementioned EMS procedure manual's statements regarding the notion that all patients delivered to the facility ED or within facility property are the primary responsibility of the facility, and that at that point, EMS has fulfilled their primary patient care obligation for EMS transportation. Staff Member #6 stated to surveyor that the county EMS procedure manual was "wrong". Staff Member #6 confirmed with surveyors that on occasion patients brought to the ED via EMS have been held within the parked ambulance outside of the EMS bay entrance prior to being registered or screened by ED staff. When asked for a facility policy or written procedure delineating such practice, Staff Member #6 stated there was no policy or procedure but that it was merely an "understood practice" for all ED staff to "not accept" a patient brought in by EMS until the ED is "ready" to triage and register the patient. Staff Member #6 confirmed with the surveyor that such patients are not included on the ED Patient Tracking Log, which displays ED patients with their corresponding chief complaint and Emergency Severity Index ("ESI") triage priority.

The surveyor inquired as to whether or not a patient presenting to the ED with a serious or life-threatening health condition would be required to wait in the ambulance without being seen. Staff Member #6 stated "no" they are "brought in right away". The surveyor asked Staff Member #6 which patients should be considered emergent enough to be brought in and treated right away, Staff Member #6 explained that although all ED patients are unique that generally speaking, any patient who is considered an ESI of "1" or "2" should be brought in the ED and treated immediately, including having a triage assessment or other MSE right away without delay.

Staff Member #6 stated to surveyors that they felt when an ED receives an EMS call for report on a patient prior to ED arrival, that such an act served as the "first triage" assessment of a patient, and thus justified keeping a patient within an ambulance outside of the facility without an initial or baseline triage assessment or MSE.

On 9/13/2022, an interview was conducted with SM #12. SM #12 acknowledged the same process, as described above by SM #6, with regard to patients arriving by EMS. SM #12 said "when the medics arrive, they will come in and give us report and if there are any changes". The surveyors inquired about the process of communicating a change in a patient's status while they are outside waiting, SM #12 said, "EMS will come in and advise of any changes". SM #12 acknowledged that acuity (ESI level) is determined "once the patient is here and triage is started".

On 9/14/2022, the surveyors revisited the process for both, receiving walk in ED patients and patients brought in by EMS, with SM #6. SM #6 when the walk-in patients present to registration, a "quick registration" is performed. This includes collecting the "name, date of birth, and chief complaint" of the patient. This information is put into the electronic medical record (EMR). If the registration staff is concerned about a patient's presentation, "they will call for a nurse to come up". If able, the patient will go to the triage room where a nurse performs multiple tasks, to include collecting more information regarding the chief complaint. During this step, the patient's ESI level is determined and documented in the EMR. Based on the patient's condition and/or presentation, the patient will follow the steps as described on 9/12/22 during the tour. There is an electronic board in the ED that displays the following: time of arrival, length of stay, name, chief complaint, ESI level and what waiting room the patient is in. The board will change colors to indicate what step of the process the patient is in. The patients arriving by EMS are not visible on this board until they are registered into the EMR. SM #6 acknowledged that the prioritization of patients is not affected by being visible on the board. Prior to registration, the charge nurse is using the form handed to them to keep track of the EMS patients outside waiting. The surveyors inquired about the process, used by the charge nurses, to keep track of the EMS patients and was advised "the patients do not get lost".

The surveyors were assisted by Staff Member #8 (Clinical Manager of the ED), Staff Member #9 (ED Nurse), and Staff Member #10 (Director of Professional Practice) with locating and reviewing the facility's medical records for the twenty-eight (28) patients brought in by EMS. The surveyors previously reviewed the EMS "run sheets" for the 28 patients which included details of the call, a narrative of the call and time stamps of the EMS unit's activity. A medical record for four (4) of the patients (#21, #23, #24 and #25) transported by EMS to the facility were not located during the search. The medical records were reviewed beginning on 09/13/22 at 9:46 am and again on 09/14/22 at 12:10 p.m. The following are excerpts of the ED patients' health information obtained by the EMS "run sheets" as well as the facility's "ED Timeline" documentation:

Patient #1: Presented with a chief complaint of an "allergic reaction". EMS arrived to facility on 01/14/22 at 4:40 p.m., accepted by facility at 6:17 p.m., Triaged at 6:27 p.m., ESI of "3".

Patient #2: Presented with a chief complaint of "fall". EMS arrived to facility on 01/06/22 at 5:22 p.m., accepted by facility at 7:19 p.m., Triaged at 7:35 p.m., ESI of "3".

Patient #3: Presented with a chief complaint of "vomiting", "nausea", and "abdominal pain". EMS arrived to facility on 01/08/22 at 4:10 p.m., accepted by facility at 5:53 p.m., Triaged at 6:03 p.m., ESI of "2".

Patient #4: Presented with a chief complaint of "cardiac issues" and "shortness of breath". EMS arrived to facility on 01/14/22 at 5:06 p.m., accepted by facility at 6:33 p.m., Triaged at 6:53 p.m., ESI of "2".

Patient #5: Presented with a chief complaint of "rescue/weakness" and "light-headedness". EMS arrived to facility on 03/19/22 at 11:06 p.m., accepted by facility at 03/20/22 at 1:54 a.m., Triaged at 2:02 a.m., ESI of "3".

Patient #6: Presented with a chief complaint of "fever". EMS arrived to facility on 06/18/22 at 10:26 p.m., accepted by facility at 10:59 p.m., Triaged at 11:04 p.m., ESI of "3".

Patient #7: Presented with a chief complaint of "ETOH [alcohol] toxicity". EMS arrived to facility on 06/13/22 at 2:20 p.m., accepted by facility at 3:11 p.m., Triaged at 3:12 p.m., ESI of "2".

Patient #8: Presented with a chief complaint of "syncope [fainting]". EMS arrived to facility on 06/17/22 at 9:51 p.m., accepted by facility at 10:45 p.m., Triaged at 10:50 p.m., ESI of "3".

Patient #9: Presented with a chief complaint of "chest pain". EMS arrived to facility on 06/18/22 at 9:35 p.m., accepted by facility at 10:09 p.m., Triaged at 10:13 p.m., ESI of "3".

Patient #10: Presented with a chief complaint of "hyperglycemia [high blood sugar]". EMS arrived to facility on 06/18/22 at 1:35 a.m., accepted by facility at 2:01 a.m., Triaged at 2:24 p.m., ESI of "3".

Patient #11: Presented with a chief complaint of "MVC [Motor Vehicle Collision]". EMS arrived to facility on 06/18/22 at 11:16 p.m., accepted by facility at 11:39 p.m., Triaged at 11:57 p.m., ESI of "3".

Patient #12: Presented with a chief complaint of "hypoglycemia [Low blood sugar]". EMS arrived to facility on 06/19/22 at 6:11 p.m., accepted by facility at 6:49 p.m., Triaged at 6:55 p.m., ESI of "2".

Patient #10: Presented with a chief complaint of "hyperglycemia [high blood sugar]". EMS arrived to facility on 06/18/22 at 1:35 a.m., accepted by facility at 2:01 a.m., Triaged at 2:24 a.m., ESI of "3".

Patient #13: Presented with a chief complaint of "ETOH [alcohol] toxicity". EMS arrived to facility on 06/19/22 at 2:21 a.m., accepted by facility at 2:44 a.m., Triaged at 2:53 p.m. [ESI score not known].

Patient #14: Presented with a chief complaint of "anxiety" and "restlessness". EMS arrived to facility on 06/18/22 at 12:28 a.m., accepted by facility at 1:01 a.m., Triaged at 1:03 a.m., ESI of "3".

Patient #15: Presented with a chief complaint of "nausea" and "vomiting". EMS arrived to facility on 06/20/22 at 5:04 p.m., accepted by facility at 5:27 p.m., Triaged at 5:29 p.m., ESI of "2".

Patient #16: Presented with a chief complaint of "chest pain". EMS arrived to facility on 07/12/22 at 2:50 a.m., accepted by facility at 3:43 a.m., Triaged at 3:46 a.m., ESI of "2" then to an ESI of "1" with a "Code STEMI" called while in the ED.

Patient #17: Presented with a chief complaint of "chest pain". EMS arrived to facility on 08/26/22 at 5:57 p.m., accepted by facility at 6:21 p.m., Triaged at 6:44 p.m., ESI of "2".

Patient #18: Presented with a chief complaint of "chest pain". EMS arrived to facility on 08/27/22 at 7:57 p.m., accepted by facility at 8:33 p.m., Triaged at 8:35 p.m., ESI of "2".

Patient #19: Presented with a chief complaint of "anxiety". EMS arrived to facility on 09/13/22 at 2:26 a.m., accepted by facility at 3:25 a.m., Triaged at 3:27 p.m., ESI of "3".

Patient #20: Presented with a chief complaint of "MVC" [Motor Vehicle Collision] and "pain". EMS arrived to facility on 01/17/22 at 11:43 p.m., accepted by facility at 01/18/22 at 12:32 a.m., Triaged at 12:38 a.m., ESI of "2".

Patient #22: Presented with a chief complaint of "Laceration to L [left] Side Of Forehead". EMS arrived to facility on 02/11/22 at 3:25 p.m., accepted by facility at 4:12 p.m., Triaged at 4:15 p.m., ESI of "1" with a "Code Trauma" called while in the ED.

Patient #26: Presented with a chief complaint of "fall with head injury". EMS arrived to facility on 06/13/22 at 1:22 p.m., accepted by facility at 11:53 p.m., Triaged at 11:55 p.m., ESI of "3".

Patient #27: Presented with a chief complaint of "leg pain". EMS arrived to facility on 06/19/22 at 11:31 p.m., accepted by facility at 12:20 a.m., Triaged at 12:20 a.m., ESI of "3".

Patient #28: Presented with a chief complaint of "fall". EMS arrived to facility on 06/12/22 at 3:25 p.m., accepted by facility at 4:00 p.m., Triaged at 4:08 p.m., ESI of "3".

The medical records for patient #16 and patient #22 were further reviewed to obtain additional information regarding patient presentation to ED and completion of an MSE.

On 09/14/22 at 10:40 a.m., the surveyors listened to the "MEDCOM" recording in the presence of Staff Member #1, Staff Member #6, and Staff Member #10 in which EMS called the facility's ED to give report on Patient #16 prior to the patient's arrival. During recording, the surveyor could hear the EMS staff member notify the facility that a "Seventy-eight [78] year old... with chest pain with pressure in chest" is in route to facility with new presenting "A. Fib" [atrial fibrillation] being seen on the cardiac monitor with "no known history of A. Fib".

On 09/14/22 at 2:12 p.m., the surveyors listened to the "MEDCOM" recording in the presence of Staff Member #1, Staff Member #6, and Staff Member #10 in which EMS called the facility's ED to give report on Patient #22 prior to the patient's arrival. Of note, EMS had called to contact the facility's ED on three [3] separate occasions. The first two calls were while the EMS was in route to the facility, while the third call was after the EMS had arrived to the facility, and was required to remain within the ambulance in the ED Bay. Facility staff informed the surveyors that the timeframe of the calls were unable to be identified.

1. During the first contact with the ED, EMS personnel stated that "bleeding is controlled", with "no loss of consciousness", and that the ETA (estimated time of arrival) was "ten (10) minutes."

2. In the second recording, the EMS staff can be heard saying, "We're pretty close", "[Patient #22] passed out from the pain", and "might need a head CT".

3. After arriving to the ED, the EMT contacted the ED physician as a concern that the patient's condition was emergent and deteriorating. The EMT can be heard telling the doctor that the patient was a "head trauma" and "possible head bleed" with "more and more combative" behavior, and was "angry and in pain". The EMT adds that the patient had one episode of loss of consciousness during transport.

The following is the EMS narrative written by the EMT for Patient #16:

"M520 was dispatched for an adult [gender] with chest pain. Upon arrival the patient was walking out of [patient's] apartment quickly and sat [patient] on the stretcher. The patient was slightly agitated with questioning upon patient contact. The patient stated that [patient] had been having chest pain for about two hours. Assessment and vitals were obtained as M520 crew was walking toward elevator to reduce delay. The patient stated that [patient's] pain was a 8 out of 10 and described it as pressure that moved to [patient's] left arm. The patient had a consistent non productive cough and stated [patient] was diagnosed with covid last week. 12 lead cables were placed on patient in elevator as we were moving to first floor then printed. The patient stated that [patient] was slightly nauseated upon onset of pain but that has subsided. The patient denied any vomiting, dizziness, abdominal pain, difficulty breathing, shortness of breath. The patient was found to be in A -Fib with no known history of it. The patients A Fib was at a controlled rate. The patients skin was warm and dry and [patient] was significantly hypertensive. The patient had ST segment depression in V 4- V6. Once in the medic unit the patient was administered 324 mg aspirin and .4 mg nitro. [Facility] was notified en route and concerns of ST depression were vocalized on report. En route the patients pain would drop from a 6-8 to a 2-3 out of 10. The patient denied difficulty breathing for duration of care. 15 lead was obtained prior to transport due to lateral and anterior depression. 20 gauge IV was established and the patients blood glucose was found to be HI. IV was run wide open for hyperglycemia. Upon arrival of ED M520 had over a 40 min delay to get into ED. 12 lead was transmitted to ED. Driver was sent in to hand deliver 12 lead to Doctor. Dr. [Staff Member #11] handed the 12 lead back to [driver] and stated they do not have beds. A total of 1.6 mg nitro was administered during wait and the patient was placed on 2 lpm oxygen. The patients lung sounds were clear but a decrease in pulse ox was observed. M520 Lead entered ER and also voiced concerns of ECG changes and chest pain and was told to come back in 10 min. Upon entering ED a code stemi was called by Dr. [Staff Member #11]."

A telephone interview was conducted with an EMS staff member present on Patient #16's call and transport to the facility. The EMS staff member will be referred to as SM #14. During the interview, SM #14 recalled the following about the patient: "Patient walked out of [patient's] senior living residence and once we got [patient] into the unit, [patient] was connected to the monitor and it showed A-fib... that is a higher acuity patient... I identified ischemic [restricted blood flow to an area of the body] changes on the 12-lead [electrodes connected to a patient that show a representation of the heart's electrical activity]... the 12- was transmitted to the hospital... I recall the patient's blood glucose was over 650, we had IV [intravenous] fluids wide open... when I called the report, I gave them [facility] history of patient's status... the patient had a very recent history of being diagnosed with COVID... when we arrived, and this is still the process, the patient and the lead provider remain inside the unit, the driver goes inside the ED to check with the charge nurse... the driver came back out to tell me there was a wait... I recall the driver went in and out several times... one of those times I gave the driver the 12-lead reading and told the driver to take it inside and find a doctor and tell them we were concerned about it... the driver came back out and told me this, '[SM #11] took it, looked at it, handed it back and said can't do anything, I don't have any beds for you'... I went in after this and went to charge desk to explain the 12-lead and the concern, I was told 'I'm doing the best I can, I need at least another 10 minutes'... when we were able to go in, we were in a hallway bed near room 14... we transitioned the patient over to the bed... [SM #11] did come in quickly and started talking to the patient... I said to [SM #11] here's the 12-lead... as soon as [SM #11] saw the 12-lead, [SM #11] activated a code stemi." SM #14 recalled this process started during the "height of COVID" and is continuing. SM #14 said with each call, "the driver goes inside to see if they are ready... we have been advised to not bring a patient in". SM #14 noted that no one from the facility comes outside to do a triage on the patient upon arrival.

On 09/13/22 at 12:44 p.m., the surveyors interviewed Staff Member #11 (ED Physician) by telephone. Staff Member #11 said, "My interaction starts when I see the patient". Staff Member #11 recalled Patient #16 and stated the following: "The patient had chest pain two hours prior to coming to the ED. The patient said 'very similar feeling as before' when the patient needed a stent. I saw the EKG and called a STEMI alert. There were dynamic changes in the EKGs; ours and EMS'." Staff Member #11 did not recall any EMS staff "coming up to me" or "handing me anything". Staff Member #11 said the EKG was handed to (Staff Member #11) by "hospital staff". Staff Member #11 said that after Patient #16 had a "cardio consult", the patient "did not meet initial criteria for STEMI". The patient was provided medical treatment for the symptoms, but Staff Member #11 noted the patient's pain "continue to get worse" and the patient was ultimately taken to the "cath lab". Catherization is a procedure involving a thin, flexible catheter that is guided through a blood vessel to assist in diagnosing or treating certain heart conditions. Staff Member #11 noted that if "EMS is concerned about a patient, there is a doctor's line they can call for advice."

The following is the EMS narrative written by the EMT for Patient #22:

"M523 was dispatched for an ALS injury of a patient who fell down the stairs with uncontrolled bleeding from the head. Aos of a single family home and was greeted by the pt's [patient's sibling] who directed crews inside the front door. The pt was sitting on the couch just inside the front door. [Patient] was an alert, GCS-15, 44 yom laying against [family member's] shoulder who was holding direct pressure on the pt's head with a towel. The family stated that the pt fell down the flight of stairs and hit [patient's] head on the wall. It was unknown how many stairs the pt fell down but there was a dent in the wall with approximately 10ml of blood beneath it. The family stated that the pt did not lose consciousness and [patient] was able to ambulate to the couch without assistance. An obvious odor of alcohol was evident on scene and the pt admitted to alcohol use. The pt was able to sit upright and was requested to remove the towel. After removal, an approximately 4 inch laceration was present on the pt's head, above [patient's] left eye. Bleed was uncontrolled. With assistance from E523M, direct pressure was applied to the injury and wrapped with 4 inch cling. A pressure dressing was applied with bleeding being controlled. The pt denied any additional complaints other than the laceration. [Patient] denied having any chest pain, difficulty breathing, or any additional injuries. A cervical collar was contraindicated due to the pt being ambulatory at the scene and denying any neck or back pain.

A primary assessment revealed that the pt was alert and able to track providers as they approached. [Patient] appeared to be breathing adequately and was able to speak in complete sentences. At times, the pt appeared to joke with providers that [patient] was fine and that [patient] didn't want to go to the hospital. A physical exam revealed the pt's pupils were equal and reactive. [Patient] then had to be talked into being transported, utilizing [family member] to help persuade [patient] to be transported. In order to prevent the pt from falling, a stair chair was brought inside. The pt sat on the stair chair but refused to be strapped down. [Patient] insisted that [patient] could walk to the stretcher and stood up. [Patient] was able to walk approximately 10 feet down a few stairs, to the stretcher in the front yard. [Patient] was secured and moved into the medic unit. Providers from E523M's crew were utilized for assistance throughout transport. Inside the medic unit, vitals were obtained and a 20g IV was established in the pt's LAC. [Patient] continued to joke with myself about being the new guy on the crew but being in charge of pt care. A reassessment of the bandage was performed and bleeding remained controlled. Pain medications were considered but contraindicated due to ETOH on board and head trauma. Per county protocols, the pt did not meet any trauma center criteria and thus transport was initiated to [Facility] ER with report called in via cell phone.

The pt was positioned in a semi-fowlers position for transport with an ongoing assessment being performed and vitals being reassessed with no signs of increased ICP. An ongoing reassessment revealed that the pt's pupils remained equal and reactive without any additional injuries or illnesses reported. While en route to [Facility], the pt's pain appeared to increase abruptly. [Patient] began to scream and kick, shouting "my head is going to explode." Small amounts of blood were noted from the bottom of the pressure dressing every time the pt strained. At one point, the pt informed providers that [patient] was going to pass out from the pain. [Patient] experienced a syncopal episode lasting approximately 10 seconds just prior to arrival at [Facility]. The pt's head was supported during the episode and [patient] was still breathing with a strong carotid pulse. [Facility] was contacted by E523M's medic who updated them of the pt's status. [Patient] regained consciousness as M523 arrived at the hospital. Once on hospital grounds, E523M's medic went inside for a room assignment and to update the charge nurse on the pt's condition. The charge nurse informed [medic] that there was no bed available at that time and that [nurse] would come out to the medic unit when a bed was ready for the pt. The pt was still alert and talking with providers and [patient's] GCS remained at 15. [Patient] appeared to be in even more pain and, at times, would punch the side wall of the medic unit. The pt started to grab at the bandage on [patient's] head, screaming for providers to take it off. [Patient] was informed that the bandage was controlling the bleeding, to which [patient] understood. After approximately 10 minutes, the pt started to grab at the bandage again, this time sliding it up off of [patient's] head. While doing so, the pt exclaimed "I am going to hit someone if this is not removed." The bleeding appeared to no longer be controlled as blood began to ooze from beneath the bandage down the pt's face. The pressure bandage and the 4 inch cling were removed. Direct pressure was then reapplied to the laceration with blood slowly soaking through the 5x9s.

After approximately 20 minutes at the hospital, E523M's medic entered [Facility] ER and updated them of the pt's situation. [Medic] informed the charge nurse of providers' concerns and asked if a doctor could come out to the medic unit and perform an assessment. [Medic] was then told by the charge nurse that the doctor wouldn't do so because if they did an assessment in the back of the medic unit, the pt would officially be theirs. At that point, E523M's additional crew were requested for assistance in the back of the medic unit. [EMS Captain] spoke with BC503 regarding the wait time and criticality of the pt. At this point, the pt continued to scream in pain and stated that [patient] was going to pass out again, to which [patient] lost consciousness for approximately 10 seconds. The pt's head was supported and [patient] was still breathing adequately with a strong carotid pulse. Shortly after, the pt regained consciousness and removed the hands of providers holding direct pressure. [Patient] removed [patient's] seat belts, sat up, and shouted at providers to take [patient] home. [Patient] was informed that providers couldn't take [patient] home and that [patient] needed to be seen in the ER. The pt's laceration began to bleed at the end of the stretcher. [Patient] had to be talked into sitting back so that providers could hold pressure on [patient's] head, to which [patient] complied. An abdominal dressing was used to hold direct pressure on the pt's head. At that point, approximately 5 minutes later, E523M's medic called the med control line and asked for direct orders to treat the pt's pain. [Physician] was informed of the protocol regarding combative patients authorizing administration of 5mg of Versed and that we also had Ketamine. The doctor stated that [doctor] did not wish to administer Ketamine or the full 5mg of Versed due to ETOH on board and head trauma. The doctor ordered 1mg of Versed and an additional 1mg after 3 minutes. After receiving the orders, Versed was drawn up and administered after a medication cross check was performed. Shortly after, the nursing supervisor came to the unit and asked for a pt update. [Nursing supervisor] stated that the pt was going straight into room CC2. The pt would not tolerate a mask for entrance into the ER. At this point, the pt was removed from the medic unit and moved directly into room CC2 where [patient] was lifted onto the hospital bed via draw sheet. The Versed appeared to help the pt as [patient] laughed with providers stating "I want more of that." Pt care was then transferred over with report provided at bedside. At one point, the pt's nurse asked how long we waited to bring the pt in and after stating that it was 46 minutes, [nurse] appeared surprised. Providers remained in the room to assist with any additional questions the ER staff had. The pt appeared to get verbally aggressive with hospital staff and became uncooperative. The ER staff then stated that the pt had a seizure, lasting approximately 10 seconds. They then administered the additional 1mg of Versed from M523 along with Ativan and Haldol. A trauma code was called and ultimately, the pt was sedated and intubated for a CT scan."

On 09/14/22 at 3:13 p.m., the