HospitalInspections.org

Based on medical record review, hospital medical staff bylaws review, employee personnel record review, hospital policy review, ambulance tracking records review, staff education record review, Patient Flow Log review, review of Paramedic report of incident, review of EMTs' reports of incident, and interview, the hospital failed to provide an initial medical screening examination for four (#31, #32, #33, #34) of four patients presenting to the Emergency Department on April 8, 2011.

Refer to findings in A-2406.

Based on medical record review, hospital medical staff bylaws review, employee personnel record review, hospital policy review, ambulance tracking records review, staff education record review, Patient Flow Log review, review of Paramedic report of incident, review of EMTs' reports of incident, and interview, the hospital failed to provide an initial medical screening examination for four (#31, #32, #33, #34) of four patients presenting to the Emergency Department on April 8, 2011. The hospital also failed to ensure Emergency Department nursing staff, who would provide emergency services, met all educational requirements for three (#1, #2, #3) of five employee records reviewed.

The hospital's failure had the potential to cause serious injury, harm, impairment, or death to the four (#31, #32, #33, #34) patients.

The findings included:

Review of Emergency Medical Systems (EMS) tracking logs dated April 8, 2011, revealed on April 8, 2011, at 7:26 p.m., two ambulances notified EMS dispatch they were transferring four patients from a motor vehicle accident to hospital #1 and this communication was available per radio to hospital #1. Continued review of tracking logs revealed at 7:29 p.m., the two ambulances transporting patients #31, #32, #33, and #34, left the scene of the accident.

Telephone interview with the Emergency Department charge nurse on April 15, 2011, at 9:46 a.m., revealed on April 8, 2011, at 7:30 p.m., the charge nurse in the Emergency Department called the Administrator on Call to state there were four patients en route and the Emergency Department would be unable to care for them with the present patient load.

Review of the Patient Flow Log revealed at 7:39 p.m., the Emergency Department of facility #1 was placed on diversion.

Review of the hospital policy entitled "Diversion Procedure", HW.PTCR.202, defined diversion as "when it is strongly recommended that new patients not be accepted due to inadequate available resources to meet additional patient needs." Continued review of the tracking logs dated April 8, 2011, revealed at 7:40 p.m., the EMS dispatch notified area ambulances that hospital #1 was on diversion. Further review of the tracking logs revealed at 7:47 p.m. the ambulance drivers from the accident scene called hospital #1 to state the patients were on the way and were told by the nurse who was working as the Unit Secretary, the hospital would not accept the patients because the Emergency Department was on diversion. Review of a written statement dated April 8, 2011, revealed the ambulance driver stated the EMS Director had advised them to take the patients to hospital #1 and the charge nurse responded they did not have the staff to accept the patients and not to bring them there. Continued review of tracking logs revealed at 7:57 p.m., the ambulances arrived at the ambulance bay (area closest to the doors where patients can be unloaded directly into the Emergency Room) of the Emergency Department of hospital #1. Review of written statements dated April 8, 2011 and untimed, the emergency personnel stated the physician on duty met the ambulance driver in the bay and said the hospital was on diversion; would not accept the patients; and to take them to another hospital. Continued review of written statements revealed the physician did not assess the patients for stability and to determine if an emergency medical condition existed. Review of tracking logs dated April 8, 2011, revealed the patients were subsequently transferred to hospital #2.

Review of the report filed by Paramedic #1 dated April 8, 2011 of events from 6:45 p.m. to 9:34 p.m., revealed patient #31, who was the mother of patients #32 and #33, wanted all four patients transferred to hospital #1 because all their medical records were there. Continued review of the report revealed patient #34 was a friend of patients #32 and #33. Patient #31 (the mother) and patient #33 (15 year old child) were transported in one ambulance (ambulance #3), and patient #32 (13 year old child) and patient #34 (14 year old child) were transported in another ambulance (ambulance # 4).

Continued review revealed about ten minutes into the transfer (no specific time given) the ambulances were advised by EMS dispatch that hospital #1 was on diversion and they could not accept patients. Continued review revealed the Paramedic contacted the supervisor (no time given) who advised to continue transport since the EMS Director had spoken to the Regional Director. Further review revealed the ambulances arrived at the Emergency Department of hospital #1 (no time given) and the EMT #1(Emergency Medical Technician) went in to notify the staff the ambulances had arrived. Continued review revealed the physician came outside, "speaking loud and throwing ... hands in the air telling the EMT that there were other hospitals in other counties and ... could take the patients there because they were not going to be accepted there." Further review revealed the Director of EMS called the Paramedic (no time given) to notify them to transfer the patients to hospital #2 which was accomplished.

Review of the report filed by EMT #2 dated April 8, 2011, revealed ten minutes out from hospital #1 (no time given) they found out hospital #1 was on diversion. Continued review revealed they called their supervisor and Director of EMS (no time given) who both stated to continue transfer to hospital #1. Further review revealed EMT #2 was met by the physician who stated they were on diversion and "we would have to go somewhere else." Continued review revealed "I told the doctor that the patients were also minors and their family wanted them transported to hospital #1 that they would meet them there." Further review revealed the physician stated "he didn't care that the patients weren't going into the Emergency Room." Continued review revealed "the Emergency Room nurses stated their director told them not to take the patients".

Review of the report filed by EMT #3 dated April 8, 2011, revealed "Halfway to hospital #1 (no time given) central dispatch advised us over the radio that hospital #1 was on diversion. We contacted our supervisor and EMS Director (no time given) who said we were to proceed to hospital #1. I attempted to make my patient call (ambulance #4) in over the radio to hospital #1 Emergency Department but they would not take any patient information. They just advised they were on full diversion. When we arrived at hospital #1 I heard the other EMT talking to the physician who said he didn't care what we had; that there were other hospitals around; and that he was not going to accept the patients; and for us to take them somewhere else."

Review of the report filed by EMT #4 dated April 8, 2011, revealed while en route to hospital #1 (no time given) in ambulance #4, they were advised it was on diversion. Continued review revealed they spoke with EMS shift supervisor (no time given) who advised them to proceed on to hospital #1. Further review revealed the EMT tried to call in to hospital #1 but Emergency Room staff would only say they were on diversion. Continued review revealed ambulance #3 was met by a physician who stated" ... was not accepting the patients that we could take them somewhere else".

Telephone interview with the Director of EMS on April 14, 2011 at 12:50 p.m. revealed "...about fourteen minutes into the transfer, about 7:40 p.m. on April 8, 2011, hospital #1 heard we were en route with four patients and they decided they were on diversion". Continued interview revealed the Director called the charge nurse of the Emergency Department at hospital #1 and stated "you can't refuse the patients because it is an EMTALA violation" to which the charge nurse replied "Oh, yes, I can." Further interview revealed the charge nurse stated "I don't care what you have in the ambulance they are not coming to (named hospital) #1".

Interview on April 14, 2011, at 2:00 p.m., in the administrative offices, with the physician on duty in the Emergency Department of hospital #1 on April 8, 2011, revealed the physician had just come on duty at 7:00 p.m. in the Emergency Department when they received a call from an ambulance bringing in two patients. Continued interview revealed the charge nurse stated the facility was on diversion and the department was really busy. Further interview revealed the diversion started about thirty to forty minutes before the ambulance call. Continued interview revealed when the ambulance arrived the charge nurse was told by the Administrator on Call to "let the ambulance know the facility is on diversion and it would be dangerous to accept the patients unless they were emergent" (medical condition manifesting itself by acute symptoms such that the absence of immediate medical attention could expect to result in serious impairment to bodily functions). Continued interview revealed the charge nurse told the physician to tell the ambulance personnel what the Administrator on Call had said. Further interview revealed the physician "felt uncomfortable doing something told to ... by a nurse who got the information from the Administrator on Call". Continued interview revealed the physician was not aware of the hospital policy on diversion but was aware the "basic principle of EMTALA is every patient who presents to the Emergency Department is entitled to a medical screening examination. Further interview revealed the physician spoke to a colleague later that evening who advised it "would have been better if I had climbed into the ambulance to assess the patients before transfer".

Telephone interview with the Director of the contracted Emergency Department physicians of hospital #1, on April 14, 2011, at 2:20 p.m., revealed the Emergency Department was on diversion on April 8, 2011, due to staffing shortage and high volume in the department. Continued interview revealed it was relayed two or three times to the ambulances by telephone and radio that the hospital was beyond its capacity and was on diversion. Further interview revealed "...in retrospect the physician should have done a medical screening examination but thought ... was representing the hospital. When the Emergency Department is in chaos it is hard to remember all aspects of the law."

Interview with the Chief Nursing Officer (CNO) on April 14, 2011, at 2:40 p.m., in the administrative offices, confirmed the CNO was the Administrator on Call on April 8, 2011. Continued interview revealed the CNO received a call from the Emergency Department between 7:00 p.m. and 7:30 p.m. stating the Emergency Department had five critical patients with eight in the waiting room and they received a call from the ambulance bringing three patients (four patients were transported) from a motor vehicle accident. Further interview revealed the nurse stated they could not do it so the CNO advised the nurse to call EMS and let them know what is going on. Continued interview revealed the charge nurse asked if the hospital was going on diversion and was told yes. Further interview revealed the nurse asked what would happen if the ambulance comes on the property and was told "...if the patient is unstable they must deal with it but help EMS understand you can't take a stable patient". Continued interview revealed when the ambulance arrived the physician went out and the decision was made to send the patients away. In further interview the CNO stated "It was the wrong thing to say to those people."

Telephone interview with the charge nurse on April 15, 2011, at 9:46 a.m., who was on duty on April 8, 2011, revealed there were fourteen patients in the Emergency Room and several in the waiting room. Continued interview revealed there was no call from the ambulance crew stating they were on the way with patients but knew they were coming after the hospital went on diversion. Further interview revealed Paramedic #1 called after the hospital was on diversion and said they heard the facility was on diversion and they were transporting three patients (four patients were transported). Continued interview with the charge nurse revealed the Paramedic was told the hospital was on diversion because the hospital exceeded capacity and ability to care for patients. Further interview revealed the ambulance called in to the Emergency Department radio and was told the facility was on diversion but did not respond. Continued interview revealed the hospital called the ambulances and asked them to acknowledge the diversion which they did but said nothing else. Further interview revealed the ambulance arrived at 8:03 p.m. and the physician appeared at the nurses' station in the Emergency Department. Continued interview revealed the charge nurse stated to the physician, "This is up to you. I don't know what else to do". Further interview revealed the physician ran through the Emergency Room's ambulance door and "I don't know what ... said but the Paramedic came in yelling and asking for everyone's names". Continued interview revealed the ambulances left and went to hospital #2.

Review of the hospital policy entitled "Patient Flow Plan: Diversion Procedure" revealed "Patients presenting to the Emergency Department of the hospital during a general and/or specific diversion status shall receive an appropriate initial medical screening and necessary stabilization." Continued policy review revealed general diversion "means no known transfer patients shall be accepted to the medical center". Further review revealed specific diversion "is implemented when a patient requiring some specific type of care which is not currently available at the medical center due to inadequate physician or human resources". Continued review of the policy revealed "The Chief Executive Officer, Chief Nursing Officer, and/or the Administrator on Call and/or Nursing Supervisor will ensure proper notification of all the entities listed below of the diversion decision utilizing the 'Diversion Notification Roster' which would include the County EMS System and Ambulance Services.

Interview with the CNO on April 14, 2011, at 4:30 p.m., in the administrative offices, initially revealed the Diversion Notification Roster had not been utilized on April 8, 2011, but the CNO spoke with the charge nurse on April 14, 2011 at 4:45 p.m. who stated Area EMS was notified but not the County Sheriff, Police Department, or other hospitals in the area.

Review of the hospital policy entitled "EMTALA - Medical Screening Protocols" revealed "A hospital may deny access to individuals when it is in "diversionary" status because it does not have the staff or facilities to accept any additional emergency individuals at that time. If the ambulance disregards the hospital's instructions and brings the individual on to hospital property, the individual has come to the emergency department and the hospital must perform an appropriate MSE (medical screening examination)".

Review of the hospital policy entitled "Medical Screening Initiative" revealed "The Medical Screening Exam (MSE) must be performed on all patients who present to the emergency department for medical care."

Review of hospital Medical Staff Bylaws, "Article VI, Emergency Medical Screening, Treatment, Transfer, and On-Call Roster Policy" Section 6.1(b) Screening revealed "Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition".

Medical record review of hospital #2 Emergency Department record revealed Patient #31 was admitted to hospital #2 on April 8, 2011, at 8:45 p.m. following a roll-over motor vehicle accident with complaints of "...pain tailbone, back, right leg, left ribs". Continued medical record review revealed the patient underwent Computerized Tomography (CT) scan of the head and cervical spine as well as x-rays of the left ribs, lumbar-sacral spine, and right knee with no abnormalities found. Further medical record review revealed the patient was discharged home at 12:15 a.m. April 9, 2011.

Medical record review of hospital #2 Emergency Department record revealed Patient #32 was admitted to hospital #2 on April 8, 2011 at 8:58 p.m., with complaints of pain in the head and had a laceration to the right scalp. Continued medical record review revealed the patient underwent a CT scan of the head and cervical spine, the CT of the head showing "Right parietal deep scalp soft tissue laceration with multiple scalp punctate radiopaque foreign bodies". Further medical record review revealed the patient required staples to close the laceration and the patient was discharged home at 12:35 a.m., on April 9, 2011.

Medical record review of hospital #2 Emergency Department record revealed Patient #33 was admitted to hospital #2 on April 8, 2011, at 8:55 p.m. with complaints of abdomen and back pain radiating to the left leg and left ankle pain. Continued medical record review revealed the patient underwent CT scan of the head, cervical spine, and abdomen with no acute findings. Further review revealed the patient's father refused an x-ray of the left ankle and the patient was discharged home at 12:10 a.m., on April 9, 2011.

Medical record review of hospital #2 Emergency Department record revealed Patient #34 was admitted to hospital #2 on April 8, 2011, at 8:45 p.m. with complaints of head and chest pain as well as pain in the left arm, elbow, wrist, hand, and knee. Continued medical record review revealed the patient underwent CT scan of the head and cervical spine which showed no abnormalities. Further medical record review revealed the patient was discharged home at 11:50 p.m. on April 8, 2011.

Review of the hospital education records for the staff of the Emergency Department at hospital #1 revealed all staff completed the on-line training for EMTALA in 2010. Continued review of education records revealed this is an annual requirement for all staff.

Review of the Emergency Department Nurse Employee Performance Evaluation revealed a section entitled "Job Specific Performance Competencies" with a subsection which stated "Meet all educational requirements: ACLS (Advanced Cardiac Life Support), PALS (Pediatric Advanced Life Support), BLS (Basic Life Support).

Review of the record of Emergency Department Employee #1, a Licensed Practical Nurse, revealed the subsection was marked with a 3, defined as "Consistently meets job requirements". Continued review of the record revealed no evidence the employee had completed ACLS, PALS, or BLS.

Review of the record of Emergency Department Employee #2, a Licensed Practical Nurse, revealed the subsection was marked with a 3, defined as "Consistently meets job requirements". Continued review of the record revealed no evidence the employee had completed ACLS or BLS.

Review of the record of Emergency Department Employee #3, a Registered Nurse, revealed the subsection was marked with a 3, defined as "Consistently meets job requirements". Continued review of the record revealed no evidence the employee had completed PALS.

During interview on April 18, 2011, at 10:45 a.m., in the administrative offices, the Risk Manager confirmed there was no evidence the employees had completed the required education. Continued interview revealed it was mandatory for all employees in the emergency department to be certified in BLS, ACLS, and PALS.

Based on medical record review, hospital medical staff bylaws review, hospital policy review, ambulance tracking records review, staff education records review, Patient Flow Log review, review of Paramedic's report of incident, review of EMTs' reports of incident, and interview, the hospital failed to provide necessary stabilizing treatment for four (#31, #32, #33, #34) of four patients presenting to the Emergency Department on April 8, 2011. The hospital's failure had the potential to cause serious injury, harm, impairment, or death to the four patients.

The findings included:

Review of Emergency Medical Systems (EMS) tracking logs dated April 8, 2011, revealed on April 8, 2011, at 7:26 p.m., two ambulances notified EMS dispatch they were transferring four patients from a motor vehicle accident to hospital #1 and this communication was available per radio to hospital #1. Continued review of tracking logs revealed at 7:29 p.m., the two ambulances transporting patients #31, #32, #33, and #34, left the scene of the accident.

Telephone interview with the Emergency Department charge nurse on April 15, 2011, at 9:46 a.m., revealed on April 8, 2011, at 7:30 p.m., the charge nurse in the Emergency Department called the Administrator on Call to state there were four patients en route and the Emergency Department would be unable to care for them with the present patient load.

Review of the Patient Flow Log revealed at 7:39 p.m., the Emergency Department of facility #1 was placed on diversion.

Review of the hospital policy entitled "Diversion Procedure", HW.PTCR.202, defined diversion as "when it is strongly recommended that new patients not be accepted due to inadequate available resources to meet additional patient needs." Continued review of the tracking logs dated April 8, 2011, revealed at 7:40 p.m., the EMS dispatch notified area ambulances that hospital #1 was on diversion. Further review of the tracking logs revealed at 7:47 p.m. the ambulance drivers from the accident scene called hospital #1 to state the patients were on the way and were told by the nurse who was working as the Unit Secretary, the hospital would not accept the patients because the Emergency Department was on diversion. Review of a written statement dated April 8, 2011, revealed the ambulance driver stated the EMS Director had advised them to take the patients to hospital #1 and the charge nurse responded they did not have the staff to accept the patients and not to bring them there. Continued review of tracking logs revealed at 7:57 p.m., the ambulances arrived at the ambulance bay (area closest to the doors where patients can be unloaded directly into the Emergency Room) of the Emergency Department of hospital #1. Review of written statements dated April 8, 2011 and untimed, the emergency personnel stated the physician on duty met the ambulance driver in the bay and said the hospital was on diversion; would not accept the patients; and to take them to another hospital. Continued review of written statements revealed the physician did not assess the patients for stability and to determine if an emergency medical condition existed. Review of tracking logs dated April 8, 2011, revealed the patients were subsequently transferred to hospital #2.

Review of the report filed by Paramedic #1 dated April 8, 2011 of events from 6:45 p.m. to 9:34 p.m., revealed patient #31, who was the mother of patients #32 and #33, wanted all four patients transferred to hospital #1 because all their medical records were there. Continued review of the report revealed patient #34 was a friend of patients #32 and #33. Patient #31 (the mother) and patient #33 (15 year old child) were transported in one ambulance (ambulance #3), and patient #32 (13 year old child) and patient #34 (14 year old child) were transported in another ambulance (ambulance # 4).


Continued review revealed about ten minutes into the transfer (no specific time given) the ambulances were advised by EMS dispatch that hospital #1 was on diversion and they could not accept patients. Continued review revealed the Paramedic contacted the supervisor (no time given) who advised to continue transport since the EMS Director had spoken to the Regional Director. Further review revealed the ambulances arrived at the Emergency Department of hospital #1 (no time given) and the EMT #1(Emergency Medical Technician) went in to notify the staff the ambulances had arrived. Continued review revealed the physician came outside, "speaking loud and throwing ... hands in the air telling the EMT that there were other hospitals in other counties and ... could take the patients there because they were not going to be accepted there." Further review revealed the Director of EMS called the Paramedic (no time given) to notify them to transfer the patients to hospital #2 which was accomplished.

Review of the report filed by EMT #2 dated April 8, 2011, revealed ten minutes out from hospital #1 (no time given) they found out hospital #1 was on diversion. Continued review revealed they called their supervisor and Director of EMS (no time given) who both stated to continue transfer to hospital #1. Further review revealed EMT #2 was met by the physician who stated they were on diversion and "we would have to go somewhere else." Continued review revealed "I told the doctor that the patients were also minors and their family wanted them transported to hospital #1 that they would meet them there." Further review revealed the physician stated "he didn't care that the patients weren't going into the Emergency Room." Continued review revealed "the Emergency Room nurses stated their director told them not to take the patients".

Review of the report filed by EMT #3 dated April 8, 2011, revealed "Halfway to hospital #1 (no time given) central dispatch advised us over the radio that hospital #1 was on diversion. We contacted our supervisor and EMS Director (no time given) who said we were to proceed to hospital #1. I attempted to make my patient call (ambulance #4) in over the radio to hospital #1 Emergency Department but they would not take any patient information. They just advised they were on full diversion. When we arrived at hospital #1 I heard the other EMT talking to the physician who said he didn't care what we had; that there were other hospitals around; and that he was not going to accept the patients; and for us to take them somewhere else."

Review of the report filed by EMT #4 dated April 8, 2011, revealed while en route to hospital #1 (no time given) in ambulance #4, they were advised it was on diversion. Continued review revealed they spoke with EMS shift supervisor (no time given) who advised them to proceed on to hospital #1. Further review revealed the EMT tried to call in to hospital #1 but Emergency Room staff would only say they were on diversion. Continued review revealed ambulance #3 was met by a physician who stated" ... was not accepting the patients that we could take them somewhere else".

Telephone interview with the Director of EMS on April 14, 2011 at 12:50 p.m. revealed "...about fourteen minutes into the transfer, about 7:40 p.m. on April 8, 2011, hospital #1 heard we were en route with four patients and they decided they were on diversion". Continued interview revealed the Director called the charge nurse of the Emergency Department at hospital #1 and stated "you can't refuse the patients because it is an EMTALA violation" to which the charge nurse replied "Oh, yes, I can." Further interview revealed the charge nurse stated "I don't care what you have in the ambulance they are not coming to (named hospital) #1".

Interview on April 14, 2011, at 2:00 p.m., in the administrative offices, with the physician on duty in the Emergency Department of hospital #1 on April 8, 2011, revealed the physician had just come on duty at 7:00 p.m. in the Emergency Department when they received a call from an ambulance bringing in two patients. Continued interview revealed the charge nurse stated the facility was on diversion and the department was really busy. Further interview revealed the diversion started about thirty to forty minutes before the ambulance call. Continued interview revealed when the ambulance arrived the charge nurse was told by the Administrator on Call to "let the ambulance know the facility is on diversion and it would be dangerous to accept the patients unless they were emergent" (medical condition manifesting itself by acute symptoms such that the absence of immediate medical attention could expect to result in serious impairment to bodily functions). Continued interview revealed the charge nurse told the physician to tell the ambulance personnel what the Administrator on Call had said. Further interview revealed the physician "felt uncomfortable doing something told to ... by a nurse who got the information from the Administrator on Call". Continued interview revealed the physician was not aware of the hospital policy on diversion but was aware the "basic principle of EMTALA is every patient who presents to the Emergency Department is entitled to a medical screening examination. Further interview revealed the physician spoke to a colleague later that evening who advised it "would have been better if I had climbed into the ambulance to assess the patients before transfer".

Telephone interview with the Director of the contracted Emergency Department physicians of hospital #1, on April 14, 2011, at 2:20 p.m., revealed the Emergency Department was on diversion on April 8, 2011, due to staffing shortage and high volume in the department. Continued interview revealed it was relayed two or three times to the ambulances by telephone and radio that the hospital was beyond its capacity and was on diversion. Further interview revealed "...in retrospect the physician should have done a medical screening examination but thought ... was representing the hospital. When the Emergency Department is in chaos it is hard to remember all aspects of the law."

Interview with the Chief Nursing Officer (CNO) on April 14, 2011, at 2:40 p.m., in the administrative offices, confirmed the CNO was the Administrator on Call on April 8, 2011. Continued interview revealed the CNO received a call from the Emergency Department between 7:00 p.m. and 7:30 p.m. stating the Emergency Department had five critical patients with eight in the waiting room and they received a call from the ambulance bringing three patients (four patients were transported) from a motor vehicle accident. Further interview revealed the nurse stated they could not do it so the CNO advised the nurse to call EMS and let them know what is going on. Continued interview revealed the charge nurse asked if the hospital was going on diversion and was told yes. Further interview revealed the nurse asked what would happen if the ambulance comes on the property and was told "...if the patient is unstable they must deal with it but help EMS understand you can't take a stable patient". Continued interview revealed when the ambulance arrived the physician went out and the decision was made to send the patients away. In further interview the CNO stated "It was the wrong thing to say to those people."

Telephone interview with the charge nurse on April 15, 2011, at 9:46 a.m., who was on duty on April 8, 2011, revealed there were fourteen patients in the Emergency Room and several in the waiting room. Continued interview revealed there was no call from the ambulance crew stating they were on the way with patients but knew they were coming after the hospital went on diversion. Further interview revealed Paramedic #1 called after the hospital was on diversion and said they heard the facility was on diversion and they were transporting three patients (four patients were transported). Continued interview with the charge nurse revealed the Paramedic was told the hospital was on diversion because the hospital exceeded capacity and ability to care for patients. Further interview revealed the ambulance called in to the Emergency Department radio and was told the facility was on diversion but did not respond. Continued interview revealed the hospital called the ambulances and asked them to acknowledge the diversion which they did but said nothing else. Further interview revealed the ambulance arrived at 8:03 p.m. and the physician appeared at the nurses' station in the Emergency Department. Continued interview revealed the charge nurse stated to the physician, "This is up to you. I don't know what else to do". Further interview revealed the physician ran through the Emergency Room's ambulance door and "I don't know what ... said but the Paramedic came in yelling and asking for everyone's names". Continued interview revealed the ambulances left and went to hospital #2.

Review of the hospital policy entitled "Patient Flow Plan: Diversion Procedure" revealed "Patients presenting to the Emergency Department of the hospital during a general and/or specific diversion status shall receive an appropriate initial medical screening and necessary stabilization." Continued policy review revealed general diversion "means no known transfer patients shall be accepted to the medical center". Further review revealed specific diversion "is implemented when a patient requiring some specific type of care which is not currently available at the medical center due to inadequate physician or human resources". Continued review of the policy revealed "The Chief Executive Officer, Chief Nursing Officer, and/or the Administrator on Call and/or Nursing Supervisor will ensure proper notification of all the entities listed below of the diversion decision utilizing the 'Diversion Notification Roster' which would include the County EMS System and Ambulance Services.

Interview with the CNO on April 14, 2011, at 4:30 p.m., in the administrative offices, initially revealed the Diversion Notification Roster had not been utilized on April 8, 2011, but the CNO spoke with the charge nurse on April 14, 2011 at 4:45 p.m. who stated Area EMS was notified but not the County Sheriff, Police Department, or other hospitals in the area.

Review of the hospital policy entitled "EMTALA - Medical Screening Protocols" revealed "A hospital may deny access to individuals when it is in "diversionary" status because it does not have the staff or facilities to accept any additional emergency individuals at that time. If the ambulance disregards the hospital's instructions and brings the individual on to hospital property, the individual has come to the emergency department and the hospital must perform an appropriate MSE (medical screening examination)".

Review of the hospital policy entitled "Medical Screening Initiative" revealed "The Medical Screening Exam (MSE) must be performed on all patients who present to the emergency department for medical care."

Review of hospital Medical Staff Bylaws, "Article VI, Emergency Medical Screening, Treatment, Transfer, and On-Call Roster Policy" Section 6.1(b) Screening revealed "Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition".

Medical record review of hospital #2 Emergency Department record revealed Patient #31 was admitted to hospital #2 on April 8, 2011, at 8:45 p.m. following a roll-over motor vehicle accident with complaints of "...pain tailbone, back, right leg, left ribs". Continued medical record review revealed the patient underwent Computerized Tomography (CT) scan of the head and cervical spine as well as x-rays of the left ribs, lumbar-sacral spine, and right knee with no abnormalities found. Further medical record review revealed the patient was discharged home at 12:15 a.m. April 9, 2011.

Medical record review of hospital #2 Emergency Department record revealed Patient #32 was admitted to hospital #2 on April 8, 2011 at 8:58 p.m., with complaints of pain in the head and had a laceration to the right scalp. Continued medical record review revealed the patient underwent a CT scan of the head and cervical spine, the CT of the head showing "Right parietal deep scalp soft tissue laceration with multiple scalp punctate radiopaque foreign bodies". Further medical record review revealed the patient required staples to close the laceration and the patient was discharged home at 12:35 a.m., on April 9, 2011.

Medical record review of hospital #2 Emergency Department record revealed Patient #33 was admitted to hospital #2 on April 8, 2011, at 8:55 p.m. with complaints of abdomen and back pain radiating to the left leg and left ankle pain. Continued medical record review revealed the patient underwent CT scan of the head, cervical spine, and abdomen with no acute findings. Further review revealed the patient's father refused an x-ray of the left ankle and the patient was discharged home at 12:10 a.m., on April 9, 2011.

Medical record review of hospital #2 Emergency Department record revealed Patient #34 was admitted to hospital #2 on April 8, 2011, at 8:45 p.m. with complaints of head and chest pain as well as pain in the left arm, elbow, wrist, hand, and knee. Continued medical record review revealed the patient underwent CT scan of the head and cervical spine which showed no abnormalities. Further medical record review revealed the patient was discharged home at 11:50 p.m. on April 8, 2011.

Review of the hospital education records for the staff of the Emergency Department at hospital #1 revealed all staff completed the on-line training for EMTALA in 2010. Continued review of education records revealed this is an annual requirement for all staff.

Based on medical record review, facility policy review, and interview, the transferring hospital failed to ensure medical records were complete for five (#7, #18, #21, #22, #26) patients requiring transfer of thirty-four patients reviewed.

The findings included:

Medical record review revealed patient #7 was admitted to the Emergency Department March 3, 2011 with complaints of abdominal pain, nausea, and vomiting. Continued medical record review revealed a Computerized Tomography Scan was completed on March 3, 2011 in the Radiology Department which showed the patient had pancreatitis and the decision was made to transfer the patient to another hospital. Review of the Physician Certification Statement for Non-Emergency Ambulance Services (required for patient transfer to another hospital) dated March 3, 2011 at 11:55 p.m., revealed the section on Medical Necessity was not completed by the physician. Review of the EMTALA Memorandum of Transfer (summary of diagnosis, documents to accompany patient, and assistance required during transfer) dated March 3, 2011 at 11:55 p.m., revealed the sections on "Mode of Transportation", Personnel Needed for Transport;", and "Support/Treatment During Transfer" were not completed by the physician.

Medical record review revealed patient #18 was admitted to the Emergency Department on February 8, 2011 with complaints of Dyspnea (difficulty breathing), Wheezing, Fever, and Change in Mental Status. Continued medical record review revealed the patient declined while in the Emergency Department requiring assistance with breathing (mechanical ventilation) and the patient was subsequently transferred to another hospital. Review of the Memorandum of Transfer form dated February 8, 2011, at 3:55 a.m., revealed the section on "Reason for Transfer" as well as the section on "Personnel Needed for Transport" and "Support/Treatment During Transfer" were not completed.

Medical record review revealed patient #21 was admitted to the Emergency Department on February 11, 2011 complaining of Left Face and Temporal Pain, Pain in Parasacral area and Left Lower Abdomen. Continued medical record review revealed the patient was seven months pregnant and requested transfer to the hospital where the obstetrician practiced. Review of the Physician Certification Statement for Non-Emergency Ambulance Services dated February 11, 2011, at 7:00 p.m., revealed it was not completed by the physician. Review of the Memorandum of Transfer dated February 11, 2011, at 7:00 p.m., revealed the section on "Patient Consent/Patient Requested" Transfer was not completed.

Medical record review revealed patient #22 was admitted to the Emergency Department on February 13, 2011 with complaints of Change in Mental Status and Speech Difficulty. Continued medical record review revealed a decision was made to transfer the patient to a hospital with neurological services. Review of the Physician Certification Statement for Non-Emergency Ambulance Services dated February 13, 2011, at 1:15 p.m., revealed the section on Medical Necessity was not fully completed by the physician. Review of the EMTALA Memorandum of Transfer dated February 12, 2011, at 1:15 p.m., revealed the sections on "Reason for Transfer", "Risk and Benefit Analysis for Transfer", "Mode of Transportation for Transfer", "Personnel Needed for Transfer", and "Support/Treatment During Transfer" were not completed by the physician.

Medical record review revealed patient #26 was admitted to the Emergency Department on February 22, 2011 with complaints of Abdominal Pain. Continued medical record review revealed the patient was diagnosed with Recurrent Cholangitis (inflammation of the bile ducts) and was to be transferred to the hospital where previous surgery had been performed. Review of the Memorandum of Transfer form dated February 22, 2011, at 7:55 p.m., revealed the sections on "Reason for Transfer", "Mode of Transportation", "Personnel Needed for Transport" and "Support/Treatment During Transfer" were not completed by the physician.

Review of the hospital policy entitled "EMTALA - Patient Transfer Protocols" revealed "...transfer to another medical facility will not be appropriate unless a physician has signed a certification that, based on the information available at the time of transfer, the medical benefits reasonable expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual. The certification must contain the reason for transfer. The physician at the transferring hospital has the responsibility for determining the appropriate mode, equipment, and attendants for transfer in such a manner as to be able to effectively manage any reasonably foreseeable complication of the individual's condition that could arise en route."

During interview on April 18, 2011, at 10:50 in the Board Room, the Director of Quality confirmed the transfer forms were not filled out completely by the physicians.