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Based on a review of policy and procedures, medical records review, video recording and interviews, it was determined that the facility failed to conduct an appropriate ongoing medical screening examination (MSE) and stabilizing treatment for one (P#1) out of 20 sampled patients. Specifically: P#1 presented to the facility on 4/22/24 at 5:19 p.m. with complaints of fevers and groin pain. P#1 had been referred to the ED by his primary care physician. A medical screening examination (MSE) was initiated at 5:50 p.m. Facility #1 (Jefferson Hospital) providers determined that P#1 required transfer to a higher level of care and was transported via stretcher out of the ED A to an ambulance via EMS staff. EMS staff determined that P#1 had a significant change in his heart rate [Normal heart rate is 60-100], while in the ED heart rate was 80-90, Heart rate increased to 160- 200 after being loaded in the ambulance, and notified staff inside the facility's ED. Facility#1's ED staff failed to reassess P#1 in the ambulance after it was reported to the ED staff of a change in the patient's heart rhythm had occurred, while the ambulance was still on Facility #1's property. Additionally, the facility failed to provide EMS staff with medication orders to treat and stabilize patient #1's increased heart rate prior to transporting the patient to Facility #2 (receiving Hospital). EMS staff obtained medication orders while in route from the receiving facility.

Refer to findings in Tags A-2406 and A-2407.

2406

Based on a review of policies and procedures, medical records, Emergency Medical Service (EMS) Patient Care Report, video recordings and interviews it was determined that facility #1 failed to provide an appropriate ongoing medical screening examination (MSE)that was within the of the hospital's emergency department for one patient (P) (P#1) of 20 sampled patients. Specifically, after P#1 was transferred into the ambulance at Facility (F)#1, he experienced a change in his heart rate. Although the ambulance remained on F#1's property, ED staff failed to re-assess P#1 for any changes increase in heart rate condition


Findings included:

A review of the facility ' s policy titled " EMTALA Screening, Stabilization and Management of Outgoing Transfers " policy# 054, last reviewed 11/2023, revealed in part, "it is the policy of the facility to provide an appropriate medical screening examination to individuals presenting to the Emergency Department requesting examination or treatment of an emergency medical condition. ,,, Emergency Medical Condition: 1. A condition manifesting itself by acute symptoms of sufficient severity (including without limitation severe pain) such as the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual ...in serious jeopardy, 2. Serious impairment to bodily functions, or serious dysfunction of a bodily organ ...Medical Screening Examination: The process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists ...Such a screening must be done with Jefferson Hospital's capability and available personnel. 1. The medical Screening examination is an ongoing process and the medical record must reflect continued monitoring based on the patient's need and continue until the patient is either stabilized or appropriately transferred."



A review of the medical record revealed that P#1 arrived at F#1's emergency department (ED) on 4/22/24 at 5:19 p.m. P#1 reported that he had been seen by his primary care physician for fevers and pain in the groin area. A medical screening examination was initiated at 5:50 p.m. by physician assistant (PA) HH. Orders included a CT (Computed Tomography- a medical imaging procedure that helps healthcare providers detect diseases and injuries) scan that was completed and read with a finding of a 4.5-centimeter infrarenal (above the kidney) aortic aneurysm (a ballooning area in the artery due to weakening of its wall). PA HH consulted with the teleradiologist who recommended an urgent consult with vascular surgery. At 9:20 p.m. PA HH spoke with Facility #1. Facility #1 Accepted P#1 for transfer.

A review of the EMS Patient Care Report revealed that the ambulance arrived at F#1 at 9:44 p.m. Continued review of the EMS Patient Care Report revealed P#1's vitals included:
10:00 p.m. Heart Rate (HR): 144 (normal: 60-100) Atrial Fibrillation (abnormal heart rhythm)
10:05:58 p.m. HR: 181 Atrial Fibrillation
10:14:12 p.m. HR: 191
A review of the EMS Patient Care Report Narrative revealed that P#1 was placed on a cardiac monitor that showed atrial fibrillation with RVR (Rapid Ventricular Response-the hearts upper chambers (atria) are beating irregularly and very fast, and the ventricles (lower chambers) are also beating to quickly in response. AFib with RVR Can be life-threatening, lead to serious complications). EMS notified F#1 ED staff of the abnormal findings. F#1 notified EMS that P#1 was now under their (EMS) care and if they (EMS) brought P#1 back into the ED, P#1 would need to be registered again. EMS left F#1 property at 10:16 p.m. EMS called F#2 for orders. Orders were received from F#2. Continued review of the EMS Patient Care Report revealed that P#1 received Amiodarone (a medication used to treat cardiac arrythmias.) at 10:29 p.m. and 10:49 p.m. P#1's HR was 163 at 11:14 p.m. EMS arrived at F#2 at 11:18 p.m.

A review of F#1's video recording
time stamped 4/22/24 from 8:43 p.m. to 10:15:55 p.m. revealed the following events:
9:48:00 p.m. - Emergency Medical Technician (EMT) OO unloaded the stretcher from ambulance.
9:48:40 p.m. -Paramedic (PM) BB and EMT OO entered the ED.
9:50:09 p.m. - PM BB and EMT OO entered P#1 ' s room with the stretcher.
9:53:00 p.m. - P#1 was on the stretcher.
9:54:45 p.m. - PM BB, EMT OO, and P#1 exited the room and went to the nurse ' s station.
9:57:24 p.m. - EMT OO wheeled P#1 out to the ambulance.
9:57:24 p.m. - PM BB remained at the nurse ' s station.
10:03:06 p.m. - PM BB exited the ED and returned to the ambulance bay.
10:03:20 p.m. - PM BB entered the ambulance ' s patient compartment.
10:04:16 p.m. - PM BB exited the patient compartment of the ambulance with cardiac lead strips in hand, entered the ED, and went to PA HH ' s office.
10:05:20 p.m. - PM BB exited the ED and returned to the ambulance bay
10:05:33 p.m. - PM BB was back inside the ambulance ' s patient compartment.
10:06:31 p.m. - RN DD stood outside the door of the ambulance ' s patient compartment and talked to someone inside of the ambulance ' s patient compartment.
10:07:37 p.m. - RN DD walked back inside the ED and went to the nurse ' s station.
10:08:17 p.m. - PM BB exited the ambulance.
10:08:19 p.m. - PM BB entered the ED with a bag in hand.
10:08:38 p.m. - PM BB stood inside PA HH ' s office.
10:09:54 p.m. - PM BB exited PA HH ' s office.
10:10:19 p.m. - PM BB exited the ED and returned to the ambulance bay.
10:10:24 p.m. - PM BB was back inside the ambulance ' s patient compartment.
10:15:55 p.m. - The ambulance left the facility ambulance bay.

An interview with PM BB took place on 5/6/24 at 3:50 p.m. in the conference room. PM BB said she remembered the event regarding P #1. PM BB recalled that PA HH replied that P #1 was stable to be transported by ambulance. PM BB stated that she was not comfortable with transporting P #1 by ambulance because of the aneurysm. PM BB said when she first saw P #1, he was stable, he went to the rest room on his own, they just assisted him into the stretcher. PM BB said when they loaded him in the ambulance and hooked him on the monitor, his heart rate was about 200 with irregular heart rhythm. PM BB said she printed the strip, went back inside, and showed it to PA HH. Paramedic HH said she also reported the patient ' s change to the Nurse Manager (RN DD) who asked her if she wanted to bring the patient back in the ED. She recalled that PA HH called her (PM BB) supervisor who ordered her to transport the patient.

A phone interview with Doctor GG took place on 5/7/24 at 4:20 p.m. Doctor GG said he was not aware of the case until he got a call from facility #2 the morning of 4/23/24 regarding a potential

A phone interview was conducted with Physician Assistant (PA) HH on 5/8/24 at 10:40 a.m. PA HH said he remembered everything about the patient (P #1) and what transpired on 4/22/24. PA HH said one of the doctors in the area sent P #1 to the ED for concerns he had about a positive blood culture. PA HH said he ordered fluid, Vancomycin (antibiotic to treat bacterial infection), and a CT scan. PA HH said it was discovered that P #1 had a pseudoaneurysm on the CT scan. PA HH said such finding was incidental. PA HH said they did not have the capability to treat an abdominal aneurysm at the facility therefore he called a local hospital they worked with and secured a transfer for the patient for higher level of care. PA HH said further Radiologist EE recommended consultation with vascular surgery which they did not have. PA HH said P #1 was fully alert and stable the entire time he was in the ED and that he did not display any sign of distress whatsoever. PA HH said it was appropriate to transport the patient by ambulance. PA PA HH said P #1 ' s blood pressure was fine, only his heart rate was high. PA HH said he and the Manager (RN DD) asked Paramedic BB to bring the patient back in the ED for re-evaluation, but she did not.

An interview with the ED manager DD took place on 5/8/24 at 3:27 p.m. in the conference room. Manager DD said she went outside, stood by the truck (ambulance) so she could lay eyes on the patient herself and continued to ask Paramedic BB to bring the patient back in the ED. RN DD said she did not bring the patient back.

The facility failed to ensure that their policy and procedure was followed as evidenced failing to ensure that on 4/212/24 Patient #1 received an appropriate medical screening examination was provided, by failing to provide further assessment of the patient's significant change in is heart rate, after the EMS personnel reported and informed Facility #1's ED staff of the changes. Patient #1 was still in the ambulance on the facility's property, the facility failed to meet the needs of the patient's newly identified EMC (tachycardia fast heart rate) significant change in the patient's condition prior to transferring the patient to Facility #2.

Based on a review of policy and procedures, medical records, and interviews, it was determined that the facility failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for one Patient (P) #1 of 20 sampled patients was stabilized as prior to transfer. Specifically, emergency medical service (EMS) staff noted, and reported to ED staff at F#1, that P#1 had a significant change in heart rate after being transferred into the ambulance, and still on hospital property (F1). Facility (F) #1 staff failed to assess the significant change, provide additional treatment or give medication orders to ensure that P#1 was stable prior to transport to facility #2.

Findings included:

A review of the facility ' s policy titled " EMTALA (Emergency Medical Treatment and Labor Act) Screening, Stabilization and Management of Outgoing Transfers " policy# 054, last reviewed 11/2023, stated in part, " To Stabilize or Stabilized: With respect to an Emergency Medical Condition, that the individual is provided such treatment as is necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from, or occur during, the transfer of the individual from the facility."


A review of the facility ' s policy titled " Patient Transfer "Depart: Nursing Service/Medical Staff policy# Nsg (Nursing) 130, Original Date: 1/76, last reviewed 9/29/23, revealed in part, " ...Emergency treatment is given to minimize aggravation of the patient's condition while in route. Responsibility for the patient during the actual transfer lies with the transferring entity.'

A review of the medical record revealed that P#1 arrived at F#1's emergency department (ED) on 4/22/24 at 5:19 p.m. P#1 reported that he had been seen by his primary care physician for fevers and pain in the groin area. A medical screening examination was initiated at 5:50 p.m. by physician assistant (PA) HH. Orders included a CT scan that was completed and read with a finding of a 4.5-centimeter infrarenal (above the kidney) aortic aneurysm (a ballooning area in the artery due to weakening of its wall). PA HH consulted with the teleradiologist who recommended an urgent consult with vascular surgery. At 9:20 p.m. PA HH spoke with F#2 Staff. F#2 Staff accepted P#1 for transfer.

A review of the EMS Patient Care Report revealed that the ambulance arrived to F#1 at 9:44 p.m. Continued review of the EMS Patient Care Report revealed P#1's vitals included:
10:00 p.m. Heart Rate (HR): 144 (normal: 60-100) Atrial Fibrillation (abnormal heart rhythm)
10:05:58 p.m. HR: 181 Atrial Fibrillation
10:14:12 p.m. HR: 191
A review of the EMS Patient Care Report Narrative revealed that P#1 was placed on a cardiac monitor that showed atrial fibrillation with RVR. EMS notified F#1 ED staff of the significant changes. F#1 notified EMS that P#1 was now under their (EMS) care and if they (EMS) brought P#1 back into the ED, P#1 would need to be registered again. EMS left F#1 property at 10:16 p.m. EMS called F#2 for orders. Orders were received from F#2. Continued review of the EMS Patient Care Report revealed that P#1 received Amiodarone (a medication used to treat cardiac arrythmias.) at 10:29 p.m. and 10:49 p.m. P#1's HR was 163 at 11:14 p.m. EMS arrived at F#2 at 11:18 p.m.


An interview with the Director of Operation Ambulance Services for the County (AA) took place on 5/6/24 at 3:34 p.m. in the conference room. Director AA explained that they provided 911 service to the entire County, and they only had two trucks in operation due to limited resources. He explained they transported patients from and to the facility. Director AA said on 4/22/24 in the late evening hours, Paramedic BB called him to report that she was about to transport a patient to facility #2 and she had some concerns about transporting the patient, PM
BB said the patient's heart rate was high when she put him in the back of the ambulance. Director AA said PM BB was in the ambulance bay when she called. Director AA said PM BB stated they (F#1) did not give her assistance with the patient. Director BB said she told PM BB to call the receiving facility for guidance. Director AA stated that Paramedic BB should have unloaded P #1 back in the ED if that was what they asked her to do. Director AA said he did not know why PM BB did not do that.

An interview with Paramedic (PM) BB took place on 5/6/24 at 3:50 p.m. in the conference room. Paramedic BB said she remembered the event regarding P #1. PM BB said when she came to the ED to check on the status of some of the pending transports. She was told P #1 was next to be transported. PM BB said she asked the ED staff what happened to flying P #1 to the facility instead. PM BB said that PA HH replied that P #1 was stable to be transported by ambulance. PM BB stated that she was not comfortable with transporting P #1 by ambulance because of the aneurysm. PM BB said when she first saw P #1, he was stable, he went to the rest room on his own, they just assisted him into the stretcher. PM BB said when they loaded him in the ambulance and hooked him on the monitor, his heart rate was about 200 with irregular heart rhythm. PM BB said she printed the strip, went back inside, and showed it to the provider PA HH, PM HH said she also reported the patient ' s change to the Nurse Manager (RN DD) who asked her if she wanted to bring the patient back in the ED. She said PA HH called her supervisor who ordered her to transport the patient.

An interview was conducted on 5/7/24 at 3:47 p.m. with Registered Nurse (RN) CC in the conference room. RN CC confirmed she was the nurse assigned to P #1 when he arrived in the ED. She confirmed that P #1 was sent to the ED from his private doctor ' s office for fluid, blood drawn, and IV medicine. RN CC said P #1 walked in the ED and came with his wife. RN CC said P #1 was stable the entire time he was in the ED.RN CC stated that the
ED had at least five occupied beds on the night of 4/22/24. RN CC further stated that she started Patient (P)#1 on intravenous fluid, drew labs, and put P#1 on a cardiac monitor. She stated that there was not a reason that she observed that indicated P#1 was in distress and needed to be transferred via air transport instead of by ground transport. RN CC said the provider was always the one who decided the mode of transport.

A phone interview with ED Doctor FF took place on 5/8/24 at 10:25 a.m. Doctor FF said he was the Emergency Department Medical Director. Doctor FF said P #1 had a history of cardiac arrythmias associated with A-fib. He said the patient was asymptomatic, and did not show any sign of distress in the ED.

A phone interview with Doctor GG took place on 5/7/24 at 4:20 p.m. Doctor GG said he was not aware of the case until he got a call from facility #2 the morning of 4/23/24 regarding a potential EMTALA violation. Doctor GG said the patient was sent to the ED from the primary care doctor ' s office for lab work and IV medications. Doctor GG said the aneurysm was an incidental finding and no one could tell how long P#1 had been living with the aneurysm. Doctor GG said he was not present to have a full evaluation of the patient; however, it was certain that a patient should be stable before transport to another facility.


A phone interview was conducted with Physician Assistant (PA) HH on 5/8/24 at 10:40 a.m. PA HH said he remembered everything about the patient (P #1) and what transpired on 4/22/24. PA HH said one of the doctors in the area sent P #1 to the ED for concerns he had about a positive blood culture. PA HH said he ordered fluid, Vancomycin (antibiotic to treat bacterial infection), and a CT scan. PA HH said it was discovered that P #1 had a pseudoaneurysm on the CT scan. PA HH said such finding was incidental. PA HH said they did not have the capability to treat an abdominal aneurysm at the facility therefore he called a local hospital they worked with and
secure a transfer for the patient for higher level of care. PA HH said further Radiologist EE recommended consultation with vascular surgery which they did not have. PA HH said P #1 was fully alert and stable the entire time he was in the ED and that he did not display any sign of distress whatsoever. PA HH said it was appropriate to transport the patient by ambulance. PA HH said P #1 ' s blood pressure was fine, only his heart rate was high. PA HH said he and the Manager (RN DD) asked PM BB to bring the patient back in the ED for re-evaluation, but she did not.

A phone interview was conducted on 5/8/24 at 11:30 a.m. with Registered Nurse (RN) II. RN II RN II stated that she remembered that Paramedic (PM) BB walked in and out of the ED twice and remembered seeing PM BB with a bag.

The facility failed to ensure that their policy was followed as evidenced by failing to provide emergency treatment to minimize the risk aggregation of the patients condition while in route, after it was reported by the EMS personnel to F #1 ED staff there was a significant change in Patient #1's heart rate (tachycardia) once he was loaded on the ambulance, and still on hospital property. Furthermore, F#1 failed to provide orders to Emergency Medical Services (EMS) to have P#1 stabilized as required prior to transport with newly identified EMC. According to record review the patient was given amiodarone for heart rate control by the EMS personnel in the ambulance at the direction of the Facility #2.