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On the days of the EMTALA investigation based on observations, interview, record reviews, review of other hospital data to include Emergency Medical Services transport notes, and review of hospital policies and procedures, the hospital failed to provide a medical screening examination to determine the existence of an emergency medical condition for one of twenty-two patient records reviewed. (Patient #22)

The findings are:

Cross Reference to A2405: The hospital failed to ensure that a patient who presented to the Emergency Department requesting to be seen was entered on the Emergency Department's central log. (Patient #22).

Cross Reference to A2406: The hospital failed to provide a medical screening examination to determine the existence of an emergency medical condition for one of one patient whose data was reviewed. (Patient #22).

Based on interviews, review of facility/patient records, Emergency Department Central Log and hospital policies and procedures, the hospital failed to ensure that the Emergency Department(ED)'s system for maintaining a central log included all individuals presenting to the Emergency Department for treatment for 1 of 1 patient data reviewed in the Emergency Department and the patient was not entered on the hospital's Central Log. (Patient #22)


The findings include:

On 02-27-12 at 1500, a review of Patient #22's data and information showed an Emergency Medical Services Encode Record dated 02-12-12 at 1935 that revealed a 59 year old male with chief complaint of seizures presented to Hospital #1's Emergency Department with an estimated time of arrival (ETA) of 3-5 minutes. The Emergency Medical Services Encode form was hand stamped by an Emergency Department staff member on 02-12-12 at 1942 upon arrival of ambulance to Hospital #1's ED. Review of the County Emergency Medical system (EMS) trip report dated 2/12/2012 revealed that the EMS unit arrived at the County Jail on 2/12/12 at 19:25 to find a 59 year old male with chief complaint of seizures. The reported stated that the patient was in the care of the fire department and detention center staff. The report showed that Fire department staff gave the following report to EMS staff upon arrival. "Fire Department stated that Jail Staff members informed them that "Patient did not receive his seizure medication do [sic] to being asleep." The EMS reported showed that upon their arrival, their assessment of the patient showed the patient was conscious, alert, and oriented to time, place, and person,was able to speak in full sentences without shortness of breath while breathing at a rate of 16 breaths per minute with clear lung sounds, had a radial pulse of of good quality at 78 beats a minute with brisk capillary refill, skin was warm, dry, and pink, displayed adequate motor and sensory function, no neurological deficits were observed, was placed on a cardiac monitor which displayed normal sinus rhythm, and an intravenous access with a number 22 gauge catheter was obtained in the left hand. The trip report reads, " Patient was continuously monitored enroute without significant changes. Hospital #2
encoded without questions or doctors orders. Patient turned over to staff in room 13." The arrival time was listed as 19:51 on 2/12/12.

Review of the Hospital #1's Emergency Department Central Log dated 2/11/12 through 2/13/12 showed Patient #22 had never been entered into the hospital's Emergency Department Central Log on either of those dates.

On 03/01/12 at 1130, a telephone interview conducted with Paramedic #1, who verified that he/she was on duty on the evening shift on 2-12-12. Paramedic #1 reported the patient was picked up from the detention center for a reported seizure times one, known history of seizures, and the patient did not receive his medication that day. Paramedic #1 reported the patient requested to be transported to Hospital #1. Paramedic #1 reported that the event was encoded-radioed to the Hospital #1's emergency department with description, age, reported seizures, history, vital signs. No physician orders were received. Paramedic #1 reported that upon arrival to Hospital
#1's Emergency Department around 1900-2000, a nurse informed us that the patient had a restraining order. Paramedic #1 reported that she informed the nurse that he/she didn't know anything about a restraining order, and this hospital was the patient's choice. Paramedic #1 stated the nurse repeated the patient can't be here because of the restraining order. The EMS crew waited a minute but the patient was not assigned a room. So, I said to the emergency department staff that we would do whatever the staff directed us to do. The nurse told us to leave.

On 02-28-12 at 1515, a telephone interview was conducted with Registered Nurse (RN) #4 who verified that he/she was on duty in Hospital #1's Emergency Department from 1900 to 0700 shift on the evening of 02-12-12 to the morning of 2-13-12. RN #4 verified that he/she took an Encode report and placed the report on the time clock so it would be stamped when the patient arrived. RN #4 stated that when the patient arrived, and he/she realized who the patient was, he/she informed the EMS crew that the patient had a restraining order. RN #4 reported the EMS crew member stated, "I forgot". RN #4 reported that he/she assumed the EMS crew knew about the restraining order also. RN #4 reported the ED staff talked among themselves, and then, the EMS attendant said that he/she would transport the patient to Hospital #2. RN #4 reported that he/she didn't know if the ED could do that, so he/she did a visual assessment of the patient which showed the patient was sitting on the stretcher calmly looking around and was cooperative. RN #4 reported that he/she had assumed that the "restraining order" and the "no trespass order" were the same type of order that meant the patient couldn't be in the hospital unless in acute distress like post ictal, coding, or active seizures. RN #4 reported that all of the staff in the ED had the same thought in that we heard the patient had a restraining order. RN #4 reported that he/she didn't realize EMTALA could occur if a patient had a restraint order.

Review of facility policy, effective 05-01-10, titled, EMTALA Definitions and General Requirements, reads, "....Central Log is a log that a hospital is required to maintain on each individual who "comes to the emergency department" seeking assistance that documents whether he or she refused treatment, was refused treatment or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged. The purpose of the Central Log is to track the care provided to each individual where EMTALA is triggered...". The facility failed to ensure that their policy and procedure on Central Log was followed on 2/12/2012 when patient #22 presented to the ED requesting medical assistance.

On the days of the EMTALA Investigation based on interview, clinical record review, review of other data and written materials, and review of facility policy and procedure, the Hospital failed to ensure that all patients that came to the Dedicated Emergency Department were given a Medical Screening Exam(MSE) to determine if an Emergency Medical Condition existed for 1 of 1 patient data reviewed in that Patient #22 did not receive a MSE. (Patient #22)


The findings include:

On 02-27-12 at 1500, a review of Patient #22's information showed an Emergency Medical Services Encode Record dated 02-12-12 at 1935 revealed a 59 year old male with chief complaint of seizures presented to Hospital #1's Emergency Department with an estimated time of arrival (ETA) of 3-5 minutes. The Emergency Medical Services Encode form was hand stamped by an Emergency Department staff member on 02-12-12 at 1942 upon arrival of ambulance to Hospital #1's ED. Review of the County Emergency Medical system (EMS) trip report dated 2/12/2012 revealed that the EMS unit arrived at the County Jail on 2/12/12 at 19:25 to find a 59 year old male with chief complaint of seizures. The reported stated that the patient was in the care of the fire department and detention center staff. The report showed that Fire department staff gave the following report to EMS staff upon arrival. "Fire Department stated that Jail Staff members informed them that "Patient did not receive his seizure medication do [sic] to being asleep." The EMS reported showed that upon their arrival, their assessment of the patient showed the patient was conscious, alert, and oriented to time, place, and person,was able to speak in full sentences without shortness of breath while breathing at a rate of 16 breaths per minute with clear lung sounds, had a radial pulse of of good quality at 78 beats a minute with brisk capillary refill, skin was warm, dry, and pink, displayed adequate motor and sensory function, no neurological deficits were observed, was placed on a cardiac monitor which displayed normal sinus rhythm, and an intravenous access with a number 22 gauge catheter was obtained in the left hand. The trip report reads, " Patient was continuously monitored enroute without significant changes. Hospital #2
encoded without questions or doctors orders. Patient turned over to staff in room 13." The arrival time was listed as 19:51 on 2/12/12. Patient #22's medical record was reviewed. Review of Hospital #2's form, titled, "Emergency Department Chart" revealed that Patient #22 arrived at Hospital #2's Emergency Department on 2/12/12 at 1950 via County EMS transport. The patient was triaged as a 3 - Urgent. Review of the Triage Notes revealed, "Per EMS, they attempted to take pt (patient) to .......medical center, were inside facility, and were told that pt had trespass notice there and "you need to take him somewhere else." Physician orders included but were not limited to: Stat Dilantin and Phenobarbital levels, Basic Metabolic Panel, Complete Blood Count. Review of the patient's lab work revealed the Dilantin Level was 21.1 ug/ml (milliliters). Therapeutic range was reported as 10.0 to 20.0 ug/ml. Potentially toxic levels were reported as greater than 20.0 ug/ml. The critical value was reported to the physician. The Phenobarbital level was recorded as 2.3 ug/ml. Optimal Therapeutic range was recorded as Adults: 20 - 40 ug/ml. Review of drug orders showed the patient received Phenobarbital 260 milligrams intravenously. The patient was discharged from the emergency department on 2/12/12 at 2209 with discharge instructions to: hold Dilantin tomorrow, Dilantin level was 21, Phenobarbital level was 2.3 got 260 mg intravenous in ED, call doctor tomorrow for recommendations to manage meds (medications).

On 03/01/12 at 1130, a telephone interview conducted with Paramedic #1 verified that he/she was on duty on the evening shift on 2-12-12. Paramedic #1 reported the patient was picked up from the detention center for a reported seizure times one, known history of seizures, and the patient did not receive his medication that day. Paramedic #1 reported the patient requested to be transported to Hospital #1. Paramedic #1 reported that the event was encoded-radioed to the Hospital #1's emergency department with description, age, reported seizures, history, vital signs. No physician orders were received. Paramedic #1 reported that upon arrival to Hospital
#1's Emergency Department around 1900-2000, a nurse informed us that the patient had a restraining order. Paramedic #1 reported that he/she informed the nurse that he/she didn't know anything about a restraining order, and this hospital was the patient's choice. Paramedic #1 stated the nurse repeated the patient can't be here because of the restraining order. The EMS crew waited a minute but the patient was not assigned a room. So, I said to the emergency department staff that we would do whatever the staff directed us to do. The nurse told us to leave. Paramedic #1 reported the patient was getting upset, stated that he did not want to be there anymore, and consented to be transported to another nearby hospital (Hospital #2). Paramedic #1 stated the EMS crew encoded to the nearby hospital (Hospital #2), and that Hospital #2 accepted the patient. Paramedic #1 verified that she did inform Hospital #2 of the situation that occurred at Hospital #1, and the reason why the patient was diverted because the Sheriff was upset about the situation that occurred at the first hospital (Hospital #1), and he/she informed Hospital #2 of the occurrence. Paramedic #2 reported that staff at Hospital #2 became inquisitive about the situation that the Sheriff was discussing with Physician #3 so I told the nurse when the nurse came to the patient. When Paramedic #1 was queried as to why there was no mention of the EMS trip to Hospital #1 on the trip ticket, Paramedic #1 responded, "I didn't consider it to be pertinent care."


On 02-28-12 at 1050, an interview with Patient Support Technician(PST)#1 verified that he/she was on duty in the Hospital #1's ED that evening. PST#1 reported that an Encode came in from the EMS crew reporting the EMS crew had a patient with seizures. PST#1 reported that when he/she returned from the bathroom, the EMS crew was in the emergency department hallway loading the patient for transport. PST#1 reported he/she asked the emergency department's Charge Nurse why the patient was leaving. PST #1 stated the Charge Nurse informed him/her that the patient had a "No Trespass Order". PST #1 reported that he/she recalled that the patient was belligerent, especially after drinking, and had been violent as in threatening staff on previous visits to the emergency department. PST#1 verified that he/she had no understanding of what a No Trespass Order was, but was informed by the Charge Nurse that the patient had a "No Trespass" order that he/she had signed on a previous visit to the emergency department.

On 02-28-12 at 1200, an interview was conducted with the Nurse Manager of Hospital #1's ED revealed that he/she first learned of the alleged incident by way of the Trident EMS Coordinator who received an e-mail from the EMS dispatch. When EMS rerouted, the dispatcher questioned the no trespass order, and this initiated the internal investigation. The ED Nurse Manager reported that the "No Trespass Order" was an inter facility document and not a restraining order issued by a court order. The ED Nurse Manager reported that the "No Trespass Order" was suggested by the ED physicians who rotate through the Hospital's Health Systems EDs. The ED Nurse Manager reported that he/she talked with the night shift in Hospital #1's ED, and the staff were confused about the meaning of a "No Trespass Order". The ED Nurse Manager reported that staff reported to him/her that they did not know if a "No Trespass Order" included everything, and that the patient shouldn't be on the hospital grounds. The Nurse Manager of the ED verified that the hospital had no policy and procedure, no legal form, and no system in place for education and communication to the ED staff when the a No Trespass order was in effect prior to the incident.

On 02-28-12 at 1515, a telephone interview was conducted with Registered Nurse (RN) #4 verified that he/she was on duty in Hospital #1's Emergency Department on 1900 to 0700 shift the evening of 02-12-12 to the morning of 2-13-12. RN #4 verified that he/she took an Encode report and placed the report on the time clock so it would be stamped when the patient arrived. RN #4 stated that when patient arrived and he/she realized who the patient was, he/she informed the EMS crew that the patient had a restraining order. RN #4 reported the EMS crew member stated, "I forgot". RN #4 reported that he/she assumed the EMS crew knew about the restraining order also. RN #4 reported that ED staff talked among themselves, and then the EMS attendant said that he/she would transport the patient to Hospital #2. RN #4 reported that he/she didn't know if the ED could do that, so he/she did a visual assessment of the patient which showed the patient was sitting on the stretcher calmly looking around and was cooperative. RN #4 reported that he/she had assumed the "restraining order" and the "no trespass order" were the same type of order that meant the patient couldn't be in the hospital unless in acute distress like post ictal, coding, or active seizures. RN #4 reported that all of the staff in the ED had the same thought in that we heard the patient had a restraining order. RN #4 reported that he/she didn't realize EMTALA could occur if a patient had a restraint order.

On 02-29-12 at 1155, a telephone interview was conducted with the Deputy Director of the County EMS who revealed the EMS crew informed him/her of the incident the next morning. The Director reported the patient called 911 with complaint of seizure, went to residence, requested transport, not sure if request was from the patient, or if the EMS crew thought the patient should go to Hospital #1. EMS encoded the trip, got to hospital (Hospital #1), went through the ED doors, and then, the Charge Nurse came up and said no because there was a restraining order on the patient. The EMS Director reported the EMS crew asked the patient if he minded going to the next hospital (Hospital #2), and the patient became aggravated. The Director reported the EMS crew transported the patient to Hospital #2. The Director stated that the EMS crew informed him/her that the charge nurse or the hospital (Hospital #1) had a restraining order on the patient. The Deputy Director stated that he/she had never heard of such a thing so he/she e-mailed the EMS Liaison at Hospital #1. The Director stated that the EMS crew reported that the charge nurse at Hospital #1 was rude to the EMS crew. The Director reported the EMS crew didn't know anything about restraining orders, and EMS crews couldn't keep track of something like that anyway.

On 02-29-12 at 1215, a telephone interview was conducted with RN #8 who verified that he/she was on duty in Hospital #1's Emergency Department from 1900 PM to 0700 AM from 02-12-12 to 02-13-12. RN #8 reported that the patient was well known in Hospital #1's ED, and the patient had a "No Trespass Order" that meant the patient was not to be seen at the facility. RN #8 reported that the patient presented to Hospital #1's ED with EMS crew transport for suspected Seizure. RN #8 reported that as soon as the patient was rolled in by the EMS crew, someone in the ED, he/she can't remember who, identified the patient had a "restraining order". RN #8 reported that the "restraining order" was communicated by hearsay. RN #8 reported that he/she was informed after the incident that the patient had a "no trespass order" and not a "restraining order". RN #8 reported that when the EMS crew was informed that the patient had a "restraining order", the attendant said he/she knew but had forgotten about the "restraining order". RN #8 reported that at that point the EMS crew left with the patient. RN #8 verified the patient wasn't at Hospital #1 more than 3-5 minutes. RN #8 verified that he/she had never received any education or training on "restraining orders" or "No Trespass Orders" prior to the incident. RN #8 verified that there were no policies and procedures or any written information about "Restraining/No Trespass Orders", and all of his/her information was just hearsay. RN #1 reported that he/she had heard the hospital was trying to do it so the patient would cease to abuse the hospital 's ED system. RN #8 reported that didn't know how the EMS crew had been made aware of the "Restraining/ No Trespass Order. RN #8 verified that no physician saw the patient. The facility failed to ensure that on 2/12/2012 Patient #22 received a Medical Screening examination that was within the capability and capacity of the hospital's ED to determine if an emergency medical condition existed. RN #8 reported that he/she was confused about what a "No Trespass or Restraining Order" meant, and that he/she thought it was a legal police order, and he/she had to abide by it. RN #8 reported that he/she was not an attorney. RN #8 reported, "If it was a restraining order, I thought the person shouldn't be on the property. I am not sure what a No Trespass order means. I thought I was doing the right thing by abiding by the hospital's decision to block this patient by further abuse of ED system." RN #8 verified the hospital had no system that included policies and procedures, staff education, and communication of such orders to ED Staff members in place prior to the incident.

On the days of the EMTALA Investigation based on interview, clinical record review, review of other data and written materials, and review of facility policy and procedure, the Hospital failed to ensure that all patients that came to the Dedicated Emergency Department were given a Medical Screening Exam(MSE) to determine if an Emergency Medical Condition existed for 1 of 1 patient data reviewed in that Patient #22 did not receive a MSE. (Patient #22)


The findings include:

On 02-27-12 at 1500, a review of Patient #22's information showed an Emergency Medical Services Encode Record dated 02-12-12 at 1935 revealed a 59 year old male with chief complaint of seizures presented to Hospital #1's Emergency Department with an estimated time of arrival (ETA) of 3-5 minutes. The Emergency Medical Services Encode form was hand stamped by an Emergency Department staff member on 02-12-12 at 1942 upon arrival of ambulance to Hospital #1's ED. Review of the County Emergency Medical system (EMS) trip report dated 2/12/2012 revealed that the EMS unit arrived at the County Jail on 2/12/12 at 19:25 to find a 59 year old male with chief complaint of seizures. The reported stated that the patient was in the care of the fire department and detention center staff. The report showed that Fire department staff gave the following report to EMS staff upon arrival. "Fire Department stated that Jail Staff members informed them that "Patient did not receive his seizure medication do [sic] to being asleep." The EMS reported showed that upon their arrival, their assessment of the patient showed the patient was conscious, alert, and oriented to time, place, and person,was able to speak in full sentences without shortness of breath while breathing at a rate of 16 breaths per minute with clear lung sounds, had a radial pulse of of good quality at 78 beats a minute with brisk capillary refill, skin was warm, dry, and pink, displayed adequate motor and sensory function, no neurological deficits were observed, was placed on a cardiac monitor which displayed normal sinus rhythm, and an intravenous access with a number 22 gauge catheter was obtained in the left hand. The trip report reads, " Patient was continuously monitored enroute without significant changes. Hospital #2
encoded without questions or doctors orders. Patient turned over to staff in room 13." The arrival time was listed as 19:51 on 2/12/12. Patient #22's medical record was reviewed. Review of Hospital #2's form, titled, "Emergency Department Chart" revealed that Patient #22 arrived at Hospital #2's Emergency Department on 2/12/12 at 1950 via County EMS transport. The patient was triaged as a 3 - Urgent. Review of the Triage Notes revealed, "Per EMS, they attempted to take pt (patient) to .......medical center, were inside facility, and were told that pt had trespass notice there and "you need to take him somewhere else." Physician orders included but were not limited to: Stat Dilantin and Phenobarbital levels, Basic Metabolic Panel, Complete Blood Count. Review of the patient's lab work revealed the Dilantin Level was 21.1 ug/ml (milliliters). Therapeutic range was reported as 10.0 to 20.0 ug/ml. Potentially toxic levels were reported as greater than 20.0 ug/ml. The critical value was reported to the physician. The Phenobarbital level was recorded as 2.3 ug/ml. Optimal Therapeutic range was recorded as Adults: 20 - 40 ug/ml. Review of drug orders showed the patient received Phenobarbital 260 milligrams intravenously. The patient was discharged from the emergency department on 2/12/12 at 2209 with discharge instructions to: hold Dilantin tomorrow, Dilantin level was 21, Phenobarbital level was 2.3 got 260 mg intravenous in ED, call doctor tomorrow for recommendations to manage meds (medications).

On 03/01/12 at 1130, a telephone interview conducted with Paramedic #1 verified that he/she was on duty on the evening shift on 2-12-12. Paramedic #1 reported the patient was picked up from the detention center for a reported seizure times one, known history of seizures, and the patient did not receive his medication that day. Paramedic #1 reported the patient requested to be transported to Hospital #1. Paramedic #1 reported that the event was encoded-radioed to the Hospital #1's emergency department with description, age, reported seizures, history, vital signs. No physician orders were received. Paramedic #1 reported that upon arrival to Hospital
#1's Emergency Department around 1900-2000, a nurse informed us that the patient had a restraining order. Paramedic #1 reported that he/she informed the nurse that he/she didn't know anything about a restraining order, and this hospital was the patient's choice. Paramedic #1 stated the nurse repeated the patient can't be here because of the restraining order. The EMS crew waited a minute but the patient was not assigned a room. So, I said to the emergency department staff that we would do whatever the staff directed us to do. The nurse told us to leave. Paramedic #1 reported the patient was getting upset, stated that he did not want to be there anymore, and consented to be transported to another nearby hospital (Hospital #2). Paramedic #1 stated the EMS crew encoded to the nearby hospital (Hospital #2), and that Hospital #2 accepted the patient. Paramedic #1 verified that she did inform Hospital #2 of the situation that occurred at Hospital #1, and the reason why the patient was diverted because the Sheriff was upset about the situation that occurred at the first hospital (Hospital #1), and he/she informed Hospital #2 of the occurrence. Paramedic #2 reported that staff at Hospital #2 became inquisitive about the situation that the Sheriff was discussing with Physician #3 so I told the nurse when the nurse came to the patient. When Paramedic #1 was queried as to why there was no mention of the EMS trip to Hospital #1 on the trip ticket, Paramedic #1 responded, "I didn't consider it to be pertinent care."


On 02-28-12 at 1050, an interview with Patient Support Technician(PST)#1 verified that he/she was on duty in the Hospital #1's ED that evening. PST#1 reported that an Encode came in from the EMS crew reporting the EMS crew had a patient with seizures. PST#1 reported that when he/she returned from the bathroom, the EMS crew was in the emergency department hallway loading the patient for transport. PST#1 reported he/she asked the emergency department's Charge Nurse why the patient was leaving. PST #1 stated the Charge Nurse informed him/her that the patient had a "No Trespass Order". PST #1 reported that he/she recalled that the patient was belligerent, especially after drinking, and had been violent as in threatening staff on previous visits to the emergency department. PST#1 verified that he/she had no understanding of what a No Trespass Order was, but was informed by the Charge Nurse that the patient had a "No Trespass" order that he/she had signed on a previous visit to the emergency department.

On 02-28-12 at 1200, an interview was conducted with the Nurse Manager of Hospital #1's ED revealed that he/she first learned of the alleged incident by way of the Trident EMS Coordinator who received an e-mail from the EMS dispatch. When EMS rerouted, the dispatcher questioned the no trespass order, and this initiated the internal investigation. The ED Nurse Manager reported that the "No Trespass Order" was an inter facility document and not a restraining order issued by a court order. The ED Nurse Manager reported that the "No Trespass Order" was suggested by the ED physicians who rotate through the Hospital's Health Systems EDs. The ED Nurse Manager reported that he/she talked with the night shift in Hospital #1's ED, and the staff were confused about the meaning of a "No Trespass Order". The ED Nurse Manager reported that staff reported to him/her that they did not know if a "No Trespass Order" included everything, and that the patient shouldn't be on the hospital grounds. The Nurse Manager of the ED verified that the hospital had no policy and procedure, no legal form, and no system in place for education and communication to t