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Based on staff interview, EMS interview, facility video monitoring review, facility documentation review and in the course of a complaint investigation, it was determined that the facility staff failed to provide an appropriate medical screening examination for one (1) of thirteen (13) patients in the survey sample, Patient #1.

The patient named in the complaint was not able to be identified. Review of the Emergency Department (ED) registration logs on and around 8/21/21, and review of the electronic medical record, yielded no patient was registered in the ED with the name and date provided by the complainant. For documentation purposes, the patient will be referred to as Patient #1.

The findings include:

On 9/14/21 at 11:25 a.m. an interview was conducted with the Director of Quality, Staff #1. When asked if video monitoring is conducted, and how long is it kept for, Staff #1 stated video monitoring in the ED areas are normally kept for 30 days however there is no audio.

On 9/14/21 at 11:30 a.m. a tour of the ED was conducted with the Unit Coordinator, Staff #5. When asked about the process off EMS bringing in a patient, Staff #5 explained they would get a call on EMS radio or by phone with estimated time of arrival and when they get here they will either assign a room or direct EMS to the triage area. Staff #5 stated the EMS calls are not recorded. When asked if EMS leaves a run report, Staff #5 explained once EMS puts their report into their computer, the reports are either printed here or faxed afterwards.

On 9/14/21 at 1:40 p.m. an interview was conducted with the ED Nursing Director, Staff #6. When asked to explain the EMS handoff process, Staff #6 stated, "Once EMS gives report to the triage nurse, care is then transferred to the ED staff. EMS would stay until triage can take report." When asked if there had been a situation when EMS did not hand off a patient and took them to another hospital, Staff #6 stated she did not recall but stated "To my understanding if they (patient) is on our property then they are our patient. We would attempt to get the patient seen by an MD." When asked if a patient requested a transfer to another hospital, Staff #6 stated, "If a patient requests a transfer we would try and get them to stay since they are here already." When asked when staff were trained on EMTALA, Staff #6 stated EMTALA was covered under new nursing orientation and during ED training.

On 9/14/21 at 2:15 p.m. the requested ED patient logs for the main hospital ED and the free standing ED were reviewed. Patient #1 was not included on any of the logs. At 3:05 p.m. Staff #6 searched for Patient #1 in the electronic medical record system and the last time a patient with the same name as in the complaint was seen, treated, and discharged from the ED was on 3/3/21. When asked if there are any logs when EMS calls, Staff #6 stated "An EMS pre-arrival form is filled out when call is received but no patient name or identifying information (only age, chief complaint, ETA). Once EMS arrives we know what information goes with that patient, for example EMS name, time of call." When asked what happens to the forms it the patient doesn't arrive, Staff #6 stated she wasn't sure but will find out.

On 9/14/21 at 3:20 p.m. Staff #6 explained she had been out sick and as she was going through emails she saw communication from the Chief of (county) EMS, Staff #15. Staff #6 stated there's an incident under investigation regarding a patient and explained per the EMS Chief that when EMS arrived with the patient on 8/21/21 an individual told them they could not accommodate the patient lying on a stretcher in the waiting room and to take them somewhere else. Staff #6 stated "I'm waiting to hear back from the Chief to discuss. The situation was unacceptable and not our practice." Staff #6 stated she spoke with the Registered Nurse on duty (Staff #14) and per Staff #14 the patient requested to stay on the stretcher and they couldn't accommodate that request. Staff #6 stated "(Name of RN) stated he did not state to transfer the patient." Staff #6 stated "If the patient wasn't quick registered I need to find out why."

On 9/14/21 at 3:50 p.m. video monitoring footage of the ED was viewed with Staff #1, Staff #6, a second surveyor, and the Manager of Safety and Security (Staff #8). The footage was started for 8/21/21 at approximately 9:30 p.m. It showed different ambulances arriving and departing with approximately six (6) ambulances within a fifteen (15) minute time span. It was viewed that on 8/21/21 at approximately 10:05 p.m. (Name of County) EMS arrived, wheeled a patient via stretcher into the ED to the triage area where an unidentified female in a blue colored shirt behind the reception desk appeared to be talking to EMS, raising/talking with her hands, then 2 EMT's rolled the stretcher with the patient on it back to the ambulance and loaded the patient back on the ambulance. The ambulance pulled away at approximately 10:11 p.m. At approximately 10:14 p.m. it was viewed that the RN, Staff #14 walked to the triage/reception area, talked with the female in the blue colored shirt then walked back into the ED treatment area at 10:15 p.m.

On 9/15/21 at 9:05 a.m. an interview was conducted with the Manager of Patient Access (Staff #9) and the Team Coordinator of Patient Access (Staff #11). Staff #9 identified the female behind the ED reception desk on 8/21/21 as Staff #12. Staff #9 stated (Name-Staff #12) is no longer employed stating it was a voluntary resignation (given prior to the event). When asked the process was at the reception desk, Staff #11 stated they would check in, sign in on the sheet. EMT gives us the name, date of birth and then triage would get report. Staff #9 stated "(registration) Staff can't advise to direct out of the hospital, someone clinical would need to see the patient first."

On 9/15/21 at 9:12 a.m. Staff #6, the ED Nursing Director, stated after emailing with the EMS Chief, "The chief stated the EMTs were trying to reach the hospital but couldn't get through via phone and called on the radio but not able to make contact and then came."

On 9/15/21 at 12:20 p.m. Staff #6 was asked if any other situation such as this one was brought to her attention. Staff #6 stated "I have not been told of any other instances." When asked what has been put in place to prevent this from happening again, Staff #6 stated, "I spoke with nurse (Name Staff #14), video was watched, the staff identified and will review EMTALA again with ED staff; will continue to communicate with EMS."

On 9/15/21 at 1:25 p.m. a phone interview was conducted with the RN Charge Nurse, Staff #14. When asked if he recalled the situation that occurred on 8/21/21 with EMT's leaving with a patient, Staff #14 stated "We had several ambulances at the same time, (Name of other hospital) was on divert. EMS presented simply, stated they were trying to call but no one took it. Told EMS we were full and directed to registration." When asked if he remembered anything about the patient, Staff #14 stated "Middle aged, no acute distress" and explained they "Had zero knowledge about the patient since we didn't get report. We didn't have a secretary." Staff #14 stated "I hadn't been out to see the patient and saw EMS leaving without reason. EMS stated "we're leaving" I asked registry what happened and she said they left." When asked if he knew the receptionist's name, Staff #14 stated he did not know the receptionist name but there has been some language barriers. When asked if he's experienced this situation before, Staff #14 stated "The greeter has no medical background and shouldn't be giving directives and haven't seen this situation before or since."

On 9/15/21 at 1:50 p.m. a phone interview was conducted with the greeter/registration staff, Staff #12, who was identified in the video footage. When asked if she recalled the situation that occurred on 8/21/21 regarding EMT's leaving the hospital with a patient, Staff #12 stated she did and stated "The patient had back pain; the charge nurse (Staff #14) said she'd have to go in a wheelchair. We had no open beds to lie her down. EMS stated "she cannot sit in a wheelchair." When asked where she was stationed and what the process is when a patient arrives, Staff #12 stated she was stationed at the front entrance and stated she would get demographics from the EMT, they would then transfer a patient to a wheelchair and then let the triage nurse know. Staff #12 stated she did not remember the conversation with the EMT's then stated "If I remember, (Other hospital name) came up in conversation." When asked if she's had EMTALA training, Staff #12 stated, "I know they can't be turned away but hasn't heard that term before today." When asked if a patient wants to leave the ED what would she do, Staff #12 stated "If someone chooses to leave, would let the triage nurse know. I never would've told EMS to go to (Other hospital name) or suggest where to go." There was no language barrier during the interview as stated by Staff #14.

On 9/15/21 at 3:00 p.m. a discussion with the Manager of Patient Access, Staff #9, who was Staff #12's supervisor included EMTALA training for the registration/reception staff. Staff #9 stated regarding EMTALA "We are not allowed to turn away a patient based on insurance" and "Leaving without being seen we immediately let triage know if they let us know they're leaving." A discussion with the ED Nursing Director, Staff #6 included if a patient came in by stretcher but no beds were available, what would be done, Staff #6 explained, "Would expect the patient to be triaged, repositioned, interventions like ice or heat, determine if someone could be moved out of a room or expedite if someone was being discharged in order to open up the room." When asked for the Chief of the county EMS' contact information, Staff #6 stated he stated he was in meetings all day but stated to communicate through email if any questions but that his emails are the information he's provided.

Staff #6 presented the email sent to her on 8/24/21 from the Deputy Chief of (Name) County Fire Rescue which read in part: "...On August 21, 2021, Medic (number) was transporting a patient to the ED and after multiple attempts to contact (Hospital Initials) by radio or phone was unable to reach them. At approx. 2200 the unit arrived and the charge nurse directed the crew to triage. The crew reported sharing a concern about the patient's ability to sit in a wheel chair unattended and the triage attendant advised the crew, "then take her to (Name of Other Hospital)". The crew then proceeded to re-load the patient and transport to (Name of Other Hospital) with no additional interaction at (Hospital Name). I wanted to bring this to your attention for review as I don't think it is appropriate for us to transport a patient to an alternate location once at the hospital. I realize your staff was likely overwhelmed at that time and perhaps the statement to go to (Name of Other Hospital) wasn't intended to be taken as an explicit request/direction, but the crew felt at a loss of what to do in that moment. Although I feel our crew was attempting to make the best possible decision for the patient, we've advised them in the future to ask to speak to the attending physician before transporting to an alternate location..."

On 9/15/21 at 6:10 p.m. an email was sent by the surveyor to the Deputy Chief of (County Name) Fire and Rescue, Staff #15, requesting to interview via phone that staff that transported the patient and interacted with the hospital staff member. At 6:55 p.m. a return email was received by Staff #15 which included, "I'll have the paramedic reach out to you by email to set up a time to talk. If you need further let me know."

Policy titled "EMTALA (Emergency Medical Treatment and Labor Act)" with a revision date of 6/15/21 read in part:
Policy Statement: Sentara will provide mandatory medical screening exams for all patients that seek care in an emergency department, or who present elsewhere on hospital property with a possible emergency medical condition, and to either provide stabilization if possible and/or if necessary, appropriately transfer of the patient to another facility."

The facility administration team was informed of the findings prior to the survey team exiting the building.

On 9/15/21 at 8:16 p.m. an email was received from the Paramedic, Staff #16 which included, "...I was the patient care provider during the event that took place at (Hospital Name) on August 21. 2021. I am more than happy to set up a time and date for an interview. I am available Friday 9/17/21 at 9:00 a.m. for a phone call..."

On 9/17/21 at 9:00 a.m. a phone interview with Staff #16 along with the other surveyor present during the inspection was conducted. When asked to describe what he remembered about the patient transferred on 8/21/21 he explained, "There were a total of 3 of us on unit (ambulance); one driver, and one rookie with me on the back. 8-10 minutes out from the hospital we tried contacting via cell 2-3 times then tried to contact via radio but unable to make contact." Staff #16 stated "We wheeled patient into first set of doors, the charge nurse was behind the desk and on the phone and pointed to triage and said "Take patient to triage." "Wheeled patient to person behind reception desk, asked if bed was available, my patient is unable to sit in wheelchair. She stated no bed was available and take patient to another hospital. Had I known (Other Hospital Name) was on divert I would not have done that." When asked if he remembered anything about the patient, Staff #16 explained they were dispatched for an unresponsive patient in the home, she was not unresponsive, she was ill and not cooperative, not helping to stand or give information. Staff #16 stated "If she was unstable we would've remained there (at the hospital)." When asked if anyone tried to stop them from leaving the hospital, Staff #16 stated, "No ma'am." When asked to explain why he felt the patient could not sit in a wheelchair, Staff #16 explained it appeared "The patient was too ill to sit in a wheelchair and when we got to (Other Hospital Name) patient was put in a wheelchair and we had to position and reposition due to (patient) slumping down."

Based on interviews and document review, it was determined the facility failed to ensure an appropriate transfer by not including the "Authorization for Transfer" (EMTALA certification) form for two (2) out of thirteen (13) patients transferred out of the facility for a higher level of care.

The findings were:

The surveyor began reviewing medical records on 09/15/21 at 9:25 am with the assistance of Staff Member #7 (Clinical Nurse Manager) and Staff Member #4 (Risk Manager). During the medical record review process, the clinical records for both Patient #9 and Patient #22 were reviewed.

Patient #9 presented to the facility Emergency Department (ED) for a non-accidental medication overdose. Patient #9 was determined to require in-patient behavioral health services not provided by facility, and was thus transferred to an outside hospital for treatment.

Patient #22 was a pediatric patient who presented to the facility for suicidal behavior. The facility again did not have services to treat inpatient pediatric behavioral health, and thus an outside transfer was deemed necessary.

The surveyor was unable to find documentation in either patient's medical records of the "Authorization for Transfer" form, also known as the Emergency Medical Treatment and Labor Act (EMTALA) transfer form.

The medical record of Patient #9 did include a "Transfer" nursing flowsheet dated 08/25/21 that provided details regarding the transferring nurse and receiving facility but the information did not include the primary source physician certification and other required criteria for EMTALA transfers.

The facility "Authorization for Transfer" form is used when a patient is transferred from the facility to an outside facility for a higher level of care. The "Authorization for Transfer" document allows for official certification of pertinent EMTALA criteria, some of which include: physician certification regarding the patient's medical condition, the medical risks and benefits associated with the transfer, patient consent, declaration that all related medical records are to be transferred with the patient, and that the receiving facility has agreed for the patient transfer.

In the afternoon of 09/14/21, the surveyors received the "EMTALA (Emergency Medical Treatment and Labor Act)" facility policy (with last revision date of 09/15/21). Under Facility Transfer Procedure "Required Action Steps" section, the policy reads, "5. Sign the SHC [Sentara Healthcare] Authorization for Transfer form performed by the Transferring Physician".

The policy continues under the "Supplemental Guidance" section to read, "The Authorization for Transfer Form must be signed, dated and timed accurately. If a verbal order to transfer [is] given, the nurse receiving the order will sign the Authorization for Transfer Form and the physician must countersign within 24 hours".

The surveyor addressed the aforementioned concerns to the facility administration staff, including Staff Member #1 (Director of Quality), Staff Member #3 (Accreditation Coordinator), and Staff Member #4 on 09/15/21 at approximately 3:00 pm. In response to the notification, the facility staff attempted to further locate the "Authorization for Transfer" EMTALA certifications for both Patient #9 and Patient #22 but were unable to present additional documentation to the surveyors.