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Based on record review, staff interview and policy review, the governing body failed to ensure the emergency department physician followed the Emergency Medical Treatment Act (EMTALA) regulations for Patient #1 regarding medical screening examination, stabilization of emergency medical condition before transfer.


Findings included ...


The hospital's policy titled; "Medical Screening for Treatment", last reviewed 9/2017 shows all patients are assessed by an Emergency Physician and/or physicians' assistant based on Emergency Severity Index Leveling.. Stabilizing medical treatment is initiated based on medical necessity and may begin before the medical screening exam is completed. Disposition of the patient from the ED is determined once the patient is stabilized ..."

According to the "Medical Staff By-laws, Rules, and Regulations", approved November 2017 for Emergency Medical Screening shows any individual who presents to the Emergency Department of the hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency condition. Generally, and "emergency medical condition" is defined as active labor or as a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serous dysfunction or impairment to bodily organ or function, or serious jeopardy to the health of the individual or unborn child.


According to the "Medical Staff By-laws, Rules, and Regulations", approved November 2017, shows "A condition of each transferred individual shall be documented in the medical record by the Physician responsible for providing the medical screening and stabilizing treatment. Upon transfer, the ED shall provide copy of appropriate medical records regarding its treatment of individual including, but not limited to, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of any test, informed written consents or transfer certification, and the name and address of any on -call Physician who had refused or failed to appear within a reasonable period of time in order to provide stabilizing treatment ..."

The hospital policy title, "Transfer from Emergency Department of Other Facilities" (ED) 1200, lasted reviewed March 2017, shows "If after the initial evaluation and stabilization of a patient the Emergency Physician deems if necessary to transfer a patient to another institution for care, the physician must contact a physician in the receiving facility to discuss the decision and get the receiving physician's signature acceptance of care for patient ..."

Patient #1 arrived in the ED (Emergency Department) of the United Medical Center (UMC) on February 16, 2018 at approximately 1:04 AM. He presented with chief complaints of gunshot wounds to the abdomen and left hand.

The surveyors conducted a telephone interview with Employee #11on February 22, 2018 at approximately 5:45 PM. The surveyors requested that the employee explain the events that occurred on February 16, 2018, with the 15-year-old GSW.

Employee #11 said, "I saw the patient walk in, told he was shot, nursing staff directed the patient to Room 8, getting signed out from another physician leaving, everybody at the bedside; appeared that the patient was being rolled out. "I asked the patient his name; "I was told that the patient was 15 years old- cut off is 16, and needed to go to the receiving Hospital (RH). I do not remember specifically who said that. I never even examined the patient."

When questioned regarding giving a report to the RH, Employee #11 stated, "Nothing to share with the emergency physician across the hall. I did not get a chance to examine the patient. Happened without me being involved, it just happened. I did not instruct anyone to take him over and I did argue with them."

Employee #11 stated his involvement with the patient precursory examination- the patient walking, talking, and intake of air in the airway, blood pressure- no blood pressure take (walking). If patient unconscious, more involved.


The surveyors conducted a telephone interview with Employee #12 on February 23, 2018, at approximately 10:30 AM. The reason for the interview explained.

Employee #12 said it gets confusing on about age limits when transferring patients to RH. "It becomes a bit of a Gray Area." Further stated that sometimes receiving hospital accept trauma patients, sometimes they do not.

The governing body failed to ensure the emergency department physician performed a medical screening examination to determine if a medical condition existed and to ensure that the emergency condition stabilized before transferred to the receiving hospital. Additionally, there was no transfer documentation on the patient from the sending hospital acknowledging the patient acceptance to the receiving hospital



Employee #1, Director of Quality, acknowledged the findings on February 22, 2018 at approximately 2:00 PM.

Based on interviews, medical record reviews, video footage, review of Emergency Medical Treatment and Labor Act (EMTALA) and hospital emergency department policies and procedures, the hospital's emergency department staff failed to conduct an appropriate Medical Screening Examination (MSE) for Patient #1, a 15 year old who presented to the Emergency Department (ED) with gunshot wounds (GSW) to the Abdomen and Left Hand.

Findings included ...

The hospital's policy titled; "Medical Screening for Treatment", last reviewed 9/2017 shows all patients are assessed by an Emergency Physician and/or physicians' assistant based on Emergency Severity Index Leveling.. Stabilizing medical treatment is initiated based on medical necessity and may begin before the medical screening exam is completed. Disposition of the patient from the ED is determined once the patient is stabilized ..."

According to the "Medical Staff By-laws, Rules, and Regulations", approved November 2017 for Emergency Medical Screening shows "Any individual who presents to the Emergency Department of the hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency condition. Generally, and "emergency medical condition" is defined as active labor or as a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serous dysfunction or impairment to bodily organ or function, or serious jeopardy to the health of the individual or unborn child ..."

Patient #1 arrived in the ED (Emergency Department) of the United Medical Center (UMC) on February 16, 2018 at approximately 1:04 AM. He presented with chief complaints of Gunshot Wounds to the Abdomen and Left hand.

A review of the video/audio footage showed the patient repeatedly knocking on the exit door adjacent to the emergency triage area. The hospital special police officer opened the door; the patient enters holding his left side with the right hand and his left arm dangling away from his body. Two women accompanied the patient; one voiced, "He's been shot." Employee #16, Triage registered nurse immediately escorts the patient to code bay #8 in the main emergency department. Six staff members responded to the code bay and assisted Patient #1 onto the stretcher at approximately 1:05 AM. Employees #14 and #15, Emergency Room Technicians began removing patient's clothing.

At approximately 1:05:22 AM, Employee #11, emergency room physician left the nurses station and proceeded towards code bay #8; at this point Employee #13, began talking to the physician as he was approaching the code bay. The physician positioned himself at the foot of the stretcher and observed the patient, no physical examination occurred.

At 1:05:53 (approximately 31 seconds lapsed), Employees #14 and #15 rolled the stretcher out of the code bay through the emergency room doors down to the receiving hospital (Children's National Medical Center Emergency Department at United Medical Center (UMC), which is approximately 200 feet down the corridor from the transferring hospital. The emergency physician returned to the nurse's station at 1:05:59, there was no evidence observed on the video footage that the physician went to the Pediatric Receiving Hospital.

Patient #1 transferred to the Pediatric Receiving Hospital Crisis Room by Employees #14 and 15 at 1:06:16 and care given to the PRH ED staff.

The hospital emergency room staff could not provide documentation regarding a medical screening examination for Patient #1. A medical screening examination is performed to determine if an emergency medical condition (EMC) exists and provide necessary stabilizing treatment.

The surveyors conducted a telephone interview with Employee #11 on February 22, 2018 at approximately 5:45 PM. When queried about the events that occurred on February 16, 2018 regarding the 15-year-old with GSW.

Employee #11ED physician said, "I saw the patient walk in, told he was shot, nursing staff directed the patient to Room 8, I was getting signed out from another physician leaving. Everybody was at the bedside; it appeared that the patient was being rolled out. I asked the patient his name; I was told that the patient was 15 years old- cut off is 16, and needed to go to the Receiving Hospital (RH). I do not remember specifically who said that. I never even examined the patient."

The surveyors queried Employee #11, physician if he gave a report to the RH? He responded, "I had nothing to share with the emergency physician across the hall. I did not get a chance to examine the patient. Happened without me being involved, it just happened. I did not instruct anyone to take him over and I did not argue with them."

Employee #11 further stated his involvement with the patient was a precursory examination- the patient was walking, talking, and intake of air in the airway, blood pressure- no blood pressure taken (walking). If patient unconscious, I would have been more involved".

The surveyors conducted a telephone interview with Employee #12, registered nurse (RN) on February 23, 2018, at approximately 10:30 AM. Emploue #12 stated "I was in the Code Bay, higher acuity patients go into the Bay. I was in the Main Core."

Employee #12 said, the patient walked in, and everyone went to assist. The staff said the patient gave name and date of birth; they determined his age 15-years-old. The employee further stated "The physician of the ED instructed us to take the patient to the RH, He said it's a policy about if the patient in 15 years or under they go to Children's" (Receiving Hospital) except for pregnancy.

The surveyors conducted a telephone interview with Employee #13, Charge Nurse (on duty at the time of the incident) on February 23, 2018, at 1:01 PM. The reason for the interview explained.

She stated other nurses at the bedside and completed the ABCs (airway, breathing, and circulation); the staff asked the patient his age; the doctor was informed and the doctor did not object to the patient's transfer to the RH. The staff informed the Employee #11, physician of the patient's age of 15-years-old and, "The physician was right there and he did not object."

Employee #13 said, Employees #14 and 15 rolled the patient to the RH and "I called the RH to alert them that the hospital is transferring a GSW. She reiterated, "Patient was on the stretcher and assessed for ABCs. He was immediately care for and he was never left unattended."

The surveyors conducted a telephone interview with Employee #14, Emergency Room Technician (ERT) on February 23, 2018, at 4:25 PM. The reason for the interview was explained to the employee. Employee #14 said he assisted with getting the patient on the stretcher a removal of the patient's clothes. Further stated; "He heard someone say that the patient was 15-years-old and was supposed to be at the RH. He [the patient] never saw the doctor. I assisted with transporting the patient to the RH.

The surveyor conducted a telephone interview with Employee #15, ERT on February 26, 2018, at 7:00 PM. The reason for the interview explained.

When queried regarding the 15-year-old patient that presented to the ED on February 16, 2018, Employee #15 said, "I went to assist with the patient. Me and another ERT removing clothes, getting ready to connect to the monitor when someone said, he was 15-year-old and should go the RH. I do what I am told, and we transported the patient to the RH."

Employee #15, ERT said the Charge Nurse at the RH said they do not "take trauma patients 15 years-old, I told her that I would let them know."

The hospital's emergency department staff failed to ensure the emergency department physician performed a medical screening examination to determine if an emergency medical condition existed, and to determine that the physician stabilized the emergency condition before transferred to the receiving hospital. Additionally, there was no transfer documentation on the patient from the sending hospital acknowledging the patient acceptance to the receiving hospital..

Employee #1, Director of Quality, acknowledged the findings on February 22, 2018 at approximately 2:00 PM.

Cross reference
A406 (§489.24(a); §489.24(c)) Appropriate Medical Screening Examination and
A409 (§489.24 (e)(1) and (2)) Appropriate Transfer.

During the investigation, the surveors noted no documented evidence of the patient's visit in the ED include registration for a medical record, medical record documentation to include nursing notes, vital signs, medical staff notes (review of systems, history and physical, medical decision) medical staff orders, treatment, discharge disposition and discharge. notes.

The hospital's emergency department staff failed to ensure the emergency department physician performed a medical screening examination to determine if an emergency medical condition existed, and to determine that the physician stabilized the emergency condition before transferred to the receiving hospital. Additionally, there was no transfer documentation on the patient from the sending hospital acknowledging the patient acceptance to the receiving hospital.

Based on interviews, medical record reviews, video footage, review of Emergency Medical Treatment and Labor Act (EMTALA) and hospital emergency department policies and procedures, the hospital failed to ensure that Patient #1 stabilized prior to transfer to the Pediatric Receiving Hospital (satellite ED located on the campus of the transferring hospital). Subsequently, the patient transferred to a higher level of care.


Finding included...

According to the "Medical Staff By-laws, Rules, and Regulations", approved November 2017, shows "A condition of each transferred individual shall be documented in the medical record by the Physician responsible for providing the medical screening and stabilizing treatment. Upon transfer, the ED shall provide copy of appropriate medical records regarding its treatment of individual including, but not limited to, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of any test, informed written consents or transfer certification, and the name and address of any on -call Physician who had refused or failed to appear within a reasonable period of time in order to provide stabilizing treatment ..."

The hospital policy title, "Transfer from Emergency Department of Other Facilities" (ED) 1200, lasted reviewed March 2017, shows "If after the initial evaluation and stabilization of a patient the Emergency Physician deems if necessary to transfer a patient to another institution for care, the physician must contact a physician in the receiving facility to discuss the decision and get the receiving physician's signature acceptance of care for patient ..."

Patient #1 arrived in the ED (Emergency Department) of the United Medical Center (UMC) on February 16, 2018 at approximately 1:04 AM. He presented with chief complaints of gunshot wounds to the abdomen and left hand.

A review of the video/audio footage showed the patient repeatedly knocking on the exit door adjacent to the emergency triage area. The hospital special police officer opened the door; the patient enters holding his left side with the right hand and his left arm dangling away from his body. Two women accompanied the patient; one voiced, "He's been shot." Employee #16, triage registered nurse immediately escorts the patient to code bay #8 in the main emergency department. Six staff members responded to the code bay and assisted Patient #1 onto the stretcher at approximately 1:05 AM. Employees #14 and #15, Emergency Room Technicians began removing patient's clothing.

At approximately 1:05:22 AM, Employee #11, emergency room physician left the nurses station and proceeded towards code bay #8; at this point Employee #13, began talking to the physician as he was approaching the code bay. The physician positioned himself at the foot of the stretcher and observed the patient, no physical examination occurred.

At 1:05:53 (approximately 31 seconds lapsed), Employees #14 and #15 rolled the stretcher out of the code bay through the emergency room doors down to the receiving hospital (Children's National Medical Center Emergency Department at United Medical Center), which is approximately 200 feet down the corridor from the transferring hospital. The emergency department physician returned to the nurse's station at 1:05:59, there was no evidence observed on the video footage that physician went to the receiving hospital.

The surveyors conducted a telephone interview with Employee #11 on February 22, 2018 at approximately 5:45 PM. When queried about the events that occurred on February 16, 2018 regarding the 15-year-old with GSW.

Employee #11, ED physician said, "I saw the patient walk in, told he was shot, nursing staff directed the patient to Room 8, I was getting signed out from another physician leaving. Everybody was at the bedside; it appeared that the patient was being rolled out. I asked the patient his name; I was told that the patient was 15 years old- cut off is 16, and needed to go to the Receiving Hospital (RH). I do not remember specifically who said that. I never even examined the patient."

The surveyors queried Employee #11, physician if he gave a report to the RH? He responded, "I had nothing to share with the emergency physician across the hall. I did not get a chance to examine the patient. Happened without me being involved, it just happened. I did not instruct anyone to take him over and I did not argue with them."

Employee #11 further stated his involvement with the patient was a precursory examination- the patient was walking, talking, and intake of air in the airway, blood pressure- no blood pressure taken (walking). If patient unconscious, I would have been more involved".

The emergency department physician failed to perform a medical screening examination to determine if medical condition existed and to determine that the physician stabilized the emergency condition before transferred to the receiving hospital. Additionally, there was no transfer documentation on the patient from the sending hospital acknowledging the patient acceptance to the receiving hospital.

Employee #1, Director of Quality, acknowledged the findings on February 22, 2018 at approximately 2:00 PM.