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Based on reviews of policies and procedures, documents, medical records, and interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases as evidenced by:

Tag A-2405 Logs

The hospital failed to ensure the Central Emergency Department (ED) Log for Abrazo Arizona Heart Hospital (AAHH) was maintained to include all patients presenting to the ED for medical services. The Central ED Log (electronic) for 05/16/2021 and 06/14/2021 did not include two (2) patients who were documented on a separate hand-written log kept by Registration staff.


Tag A-2406 Appropriate Medical Screening Examination:

The hospital failed to ensure that an appropriate medical screening examination (MSE) was performed on Patient #1 after the patient presented to the Emergency Department at Abrazo Arizona Heart Hospital (AAHH) via Emergency Medical Services (EMS). EMS was met by hospital staff in the hospital's parking lot and were redirect to another hospital.

The cumulative effect of these systematic deficient practices resulted in the hospital's inability to ensure the provision of compliance with 489.24 EMTALA requirements related to maintaining a central ED Log and Appropriate Medical Screening Examination (MSE).

Based on review of policies and procedures, documents, medical records, and interviews, it was determined that the hospital failed to ensure the Central Emergency Department (ED) Log for Abrazo Arizona Heart Hospital (AAHH) was maintained to include all patients presenting to the ED for medical services. The Central ED Log (electronic) for 05/16/2021 and 06/14/2021 did not include two (2) patients who were documented on a separate hand-written log kept by Registration staff. This deficient practice poses a potential risk to the health and safety of patients when the hospital is not accountable and cannot/does not track all patient(s) presenting to the ED requesting services.

Findings include:

The policy and procedure titled "EMTALA" revealed: "...V. Procedure...C. Central Log 1. The hospital must maintain a central log of individuals who come to the emergency department and include in such log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged. The log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE...."

Central ED logs were requested from all four dedicated ED's and provided in electronic format. The ED log from AAHH for 5/16/2021 did not include Patient #1. A separate hand-written ED "Patient Refusal to be Seen Log" from AAHH was then provided which was explained by Director-Staff #6 to be a log kept by Registration staff for patients who walk in but leave prior to being registered. Two of four patients on the handwritten log between the period of 04/26/2021 and 06/14/2021 were not on the electronic ED log including Patient #1 on 05/16/2021 and Patient #44 who presented on 06/14/2021.

Director-Employee #1 reported during an interview conducted on 06/22/2021, that s/he was not aware that Registration staff kept a separate log and confirmed that both Patient #1 and Patient #44 should have been entered into the central log.

Based on review of policies and procedures, documents, medical records, and staff interviews, it was determined the hospital failed to ensure that an appropriate medical screening examination (MSE) was performed on Patient #1 after the patient presented to the Emergency Department at Abrazo Arizona Heart Hospital (AAHH) via Emergency Medical Services (EMS). EMS was met by hospital staff in the hospital's parking lot and were redirect to another hospital. This deficient practice poses a potential risk of harm to patients that may have a medical emergency and are diverted to another facility without any medical screening exam being performed.

Findings include:

Policy titled "EMTALA" revealed: "DEFINITIONS...E. Hospital Property means the entire main Hospital campus, including the physical area immediately adjacent to the Hospital's main buildings (e.g., parking lots, sidewalks, and driveways), and other areas and structures that are not attached to the Hospital's main building but are located within 250 yards of the Hospital's main buildings...IV. Policy: If an individual comes to the Emergency Department: A. The Hospital will provide an appropriate medical screening examination within the capability of the Hospital's Dedicated Emergency Department...to determine whether or not an emergency medical condition exists...V. Procedure...B. Medical Screening Examination 1. The Hospital shall provide a medical screening examination to any individual who comes to the Emergency Department...."

The policy and procedure titled "Provision of Care and Services" revealed: "...Department: Emergency Departments...The objective of our Emergency Departments is to provide medical screening evaluation and identification of emergency medical conditions, prioritization (triage) for treatment and prioritized medical interventions...." AAHH was documented to be accredited by The Society of Chest Pain as a Chest Pain Center with Percutaneous Coronary Intervention. AAHH was described in the policy to: "...have electrophysiology capabilities and...also designated cardiac centers listed with the Arizona Emergency Medical Services."

The policy and procedure titled "STEMI (ST-segment elevation myocardial infarction), NSTEMI, ACS (Acute Coronary Syndrome)" revealed: "...II. Policy: The following standards pertain to adult patients in the emergency department...experiencing signs and symptoms of acute coronary syndrome (ACS) or acute myocardial infarction (AMI)...B. EMS arrivals: The patient will be immediately taken into an ED room. C. Immediate assessment is performed by the ED physician...."

Emergency Medical Services (EMS) medical record revealed that Patient #1 was taken by ambulance to AAHH on 05/16/2021. The Emergency Medical Services (EMS) narrative revealed that Patient #1 was found sitting down outside his/her house, alert, and oriented x 4, however in distress. Patient #1 complained of chest pain, pressure, and radiating to the patient's back. EMS was on the scene at 22:47, left at 22:59, and transfer care to hospital was at 23:22. The EMS narrative included: Patch to AAHH as a STEMI and no issue. Upon arrival to AAHH, hospital staff met EMS in the parking lot. Hospital staff revealed that they could no longer take the patient because they had just received a STEMI that had just flown in and would delay Patient #1's treatment. EMS diverted to Hospital #2 and EMS notified Hospital #2 of STEMI. Patient #1 was identified as "John Doe" on the "Patient Refusal to be Seen Log" maintained by Registration staff but was not on the Central ED log (Refer to Tag 2405 for more details).

Documentation in the clinical records from Hospital #2 revealed Patient #1 arrived by ambulance with complaint of chest pain, and was seen by a provider at 23:25. Patient #1's medical history included a myocardial infarction (MI), cardiac stents, and hyperlipidemia. The patient received 3 doses of nitroglycerin prior to arrival and reported that his/her symptoms improved. Patient had a left bundle branch block pattern EKG with no ST elevation that met Sgarbossa's criteria. Due to the patient's risk factors, the patient was admitted for further cardiology evaluation.

Hospital document dated "05/19/2021" revealed that RN-Employee #17, had taken the patch call informing the ED of a possible STEMI. RN-Employee #11, notified the House Supervisor-Employee #16 of the incoming ambulance. House Supervisor-Employee #16 was on the helipad with another incoming STEMI. Document revealed conflicting statements from the House Supervisor-Employee #16 and RN-Employee #17. Interview with House Supervisor-Employee #16 revealed that the House Supervisor-Employee #16 would be down and they would figure it out, however RN-Employee #11 confirmed that s/he was instructed by House-Supervisor-Employee #16 to divert the ambulance. RN-Employee #11 met the ambulance and told EMS that per the supervisor they could not take the patient because they had a helicopter landing. The EMS driver said "OK". House Supervisor-Employee #16 arrived at the ED and was told that the ambulance had been diverted. The ED staff were unaware of a helicopter landing prior to the call to House Supervisor-Employee #16 and the patch call from EMS. The hospital found that there had been a mis-communication between the House Supervisor and the ED nurse/ED Staff.

RN-Employee #11 confirmed during an interview conducted on 06/23/2021 at AAHH that the facility has the ability to do two (2) STEMI's at night. The staff call and begin to stabilize the patient. On 05/16/2021, the ED received a patch call and RN-Employee #11 notified the House Supervisor-Employee #16 that an ambulance was in route. S/he was instructed to divert the patient and to tell the ambulance that the facility could not take the patient. RN-Employee #11 could hear EMS approaching, met the ambulance, and then notified EMS of the diversion. S/he had never diverted an ambulance and then notified his/her manager.

Director-Employee #14 confirmed during an interview conducted on 06/23/2021, that the incident occurred due to a communication error. The House Supervisor should notify the Emergency Department (ED) of any incoming emergencies via helicopter. The HS did not notify the ED of the incoming emergency via helicopter. The staff involved were educated on the need for communication.

The hospital's Corrective Action included: On 5/20/2021, communication regarding EMTALA was sent to all staff; On 05/21/2021, hospital reviewed EMTALA training and policies and all providers were assigned Annual EMTALA training due by 08/23/2021. On 05/24/2021, Refresher EMTALA education assigned to ED, House Supervisor, and Cath lab staff; Staff involved were instructed during interviews the EMTALA process.

Hospital documents dated "05/20/2021 & 06/04/2021" revealed that emails were sent to all Hospital staff at the AAHH reminding staff that any patient presenting to the facility needs a medical screening exam, the campus is anything within 250 yards, and transfer through the appropriate transfer process. Manager-Employee #7 confirmed during an interview conducted on 06/23/2021, that s/he had staff sign off on email dated 05/20/2021, regarding their understanding and compliance of medical screening exams. Nine (9) out of fourteen (14) staff had signed acknowledgement.

Hospital document titled "ER EMTALA - Refresher Education" revealed that the course titled, "2020 EMTALA Recording Training" was assigned to all staff at each dedicated ED with a completion deadline of 06/30/2021. As of 06/23/2021, 37 out of 92 employees had completed their EMTALA Refresher Education.

RN-Employee #10 and RN-Employee #15 reported during separate interviews conducted on 06/22/2021 at Abrazo Arrowhead Campus that EMTALA training is completed every year but they were not aware of any new training for EMTALA.

In summary, Patient #1 was taken the the ED of Abrazo Arizona Heart Hospital by EMS on 05/16/2021 with a chief complaint of chest pain and pressure radiating to the back. An employee met the ambulance outside of the ED and reported they could not take the patient and EMS transported the patient to Hospital #2. The hospital identified the EMTALA violation and initiated a corrective action plan on 05/20/2021. All ED staff at Abrazo Arizona Heart Hospital were provided with additional EMTALA training, however, only 37 out of 92 employees from Abrazo Arrowhead Campus, Abrazo Surprise Hospital, and Abrazo Peoria Emergency Center had completed the training as of 6/23/2021.