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Based on review of facility policy and staff interviews, Facility A failed to provide an appropriate Medical Screening Examination (MSE) for one patient (#1) in transfer from Facility B. Patient #1 was diverted from Facility A's ambulance bay, without being seen with an Elevated Blood Pressure, Headache and Brain Fog to Facility C's emergency department (ED). This affected one out of 19 ED patient records reviewed.

The findings include:

Review of the facility policy, "EMTALA-Tennessee Medical Screening Examination and Stabilization," last reviewed 12/2024, revealed "...An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED)...Such obligation is further extended to those individuals presenting elsewhere on hospital property requesting examination or treatment for an emergency medical condition...The individual arrives on the hospital property other than a DED and makes a request or another makes a request on the individual's behalf for examination or treatment...The individual arrives on the hospital property either in the DED or property other than the DED, and no request is made for evaluation or treatment, but the appearance of behavior of the individual would cause a prudent layperson observer to believe that the individual needed such examination or treatment..."

Patient #1 was a 16-year-old male inpatient at Facility B on 7/22/2025, who developed High Blood Pressure, Headache, and Brain Fog. It was determined Patient #1 needed to be sent to Facility A's Emergency Department (ED) for further evaluation. Patient #1 was transported by EMS to Facility A's ED ambulance bay. Patient #1 was never transferred from the ambulance into Facility A's ED. Facility A's ED Physician called Facility B's House Supervisor and told the House Supervisor to send Patient #1 to Facility C's Children's ED. Patient #1 did not have a Medical Screening Examination performed at Facility A's ED. There is no medical record for Patient #1 at Facility A's ED on 7/22/2025, since after arriving at Facility A's ED, Patient #1 was never brought into the ED.

Cross Refer to A-2406.

Based on review of facility policy, review of facility video and pictures, medical record review and staff interviews, the facility failed to keep an accurate Emergency Department Log for 1 patient, Patient #1 who was diverted from Facility A's Ambulance Bay without being seen to Facility C's Emergency Department (ED) of 19 ED medical records reviewed.

The findings include:

Review of the facility policy, "EMTALA-Tennessee Central Log Policy, " last reviewed 12/2024, revealed "The hospital will maintain a Central Log containing information on each individual who comes on the hospital campus requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination ("MSE") could be performed, whether he or she refused treatment, whether he or she was refuse treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged."

Review of Facility A's video tape and Security still pictures from the video were reviewed onsite. Facility A was unable to submit the Security video tapes, but provided the still picture for the investigation. The video and pictures revealed the EMS ambulance, which contained Patient #1 was parked in Facility A's ED ambulance bay. The review of the video and pictures revealed Patient #1 was never removed from the ambulance and taken into Facility A's ED.

Medical record review from Facility B revealed Patient #1 was a 16-year-old male in-patient at Facility B on 7/22/2025. Patient #1 developed High Blood Pressure, Headache and Brain Fog. It was determined Patient #1 needed to be sent to Facility A's ED for further evaluation. Facility A's ED and Facility B are located on the same property. There is no medical record for Patient #1 at Facility A's ED on 7/22/2025 due to Patient #1 was not brought into Facility A's ED. There is no listing of Patient #1 on Facility A's Central Emergency Department Log. Patient #1 was directed by Facility A's ED Physician to be transferred to Facility C's ED.

During a telephone interview on 7/30/2025 at 3:11 PM, RN #2 stated on 7/22/2025 a medic (EMT) came in the front door of the ED. RN #2 stated "did not see" Patient #1 and "did not receive" any report. RN #2 stated Patient #1's name was not on Facility A's ED log because Patient #1 never came inside the facility. RN #2 stated the ED Physician told EMS to take the patient to Facility C.

During an interview on 7/31/2025 at 10:20 AM, with the Vice-President of Quality, Safety, and Regulatory stated Patient #1's name was not on the emergency department log and there was no medical record of this patient in the PNED.

Based on review of facility policy, review of facility video and pictures, medical record review and staff interviews, the facility failed to provide an appropriate Medical Screening Examination (MSE) for 1 patient (#1) who was diverted from the facility's ambulance bay without being seen to another facility's emergency department (ED) of 19 ED patient records reviewed.

The findings include:

Review of the facility policy,"EMTALA-Tennessee Medical Screening Examination and Stabilization," last reviewed 12/2024, revealed "...An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED)...Such obligation is further extended to those individuals presenting elsewhere on hospital property requesting examination or treatment for an emergency medical condition...The individual arrives on the hospital property other than a DED and makes a request or another makes a request on the individual's behalf for examination or treatment...The individual arrives on the hospital property either in the DED or property other than the DED, and no request is made for evaluation or treatment, but the appearance of behavior of the individual would cause a prudent layperson observer to believe that the individual needed such examination or treatment..."

Review of Facility A's video tape and Security still pictures from the video were reviewed onsite. Facility A was unable to submit the Security video tapes, but provided the still picture for the investigation. The video and pictures revealed the EMS ambulance, which contained Patient #1, was parked in Facility A's ED ambulance bay. The review of the video and pictures revealed Patient #1 was never removed from the ambulance and taken into Facility A's ED.

Medical record review from Facility B revealed Patient #1 was a 16-year-old male in-patient at Facility B. Patient #1 developed a High Blood Pressure, Headache and Brain Fog. It was determined Patient #1 needed to be sent to the Facility A's ED for further evaluation. Facility A's ED and Facility B are located on the same property. There is no medical record for Patient #1 at Facility A's ED on 7/22/2025 due to Patient #1 was not brought into Facility A's ED. Patient #1 was directed by Facility A's ED Physician to be transferred to Facility C's ED. Patient #1 did not receive a MSE.

During a telephone interview on 7/29/2025 at 7:30 PM, RN #1 stated an Emergency Medical Services (EMS) personal, an Emergency Medical Technician (EMT) went through Facility A's ED on 7/22/2025 on the way to the restroom. Interview revealed the EMT spoke to the ED nurses and shared Facility B was sending a 16-year-old hypertensive patient with slurred speech. RN #1 stated the ED Physician overheard the conversation and started asking questions. RN #1 stated she telephoned Facility B so the ED Physician could speak directly with the House Supervisor about Patient #1. RN #1 stated the ED Physician told the House Supervisor she was not refusing the patient, but if the patient was having a stroke, the patient would be better off at Facility C's ED. The ED Physician told the House Supervisor at Facility B if Patient #1 was bought to Facility A's ED, she was going to turn around and transfer the patient to Facility C's ED. RN #1 stated Facility A's ED did not get a called nursing report from Facility B like they normally do when Facility B sends them patients. RN #1 stated she did not know Patient #1 was in Facility A's ED ambulance bay at that time the EMT came into the ED to use the restroom and shared information.

During a telephone interview on 7/30/2025 at 3:11 PM, RN #2 stated on 7/22/2025 a medic (EMT) came in the front door of the ED. RN #2 stated "did not see" Patient #1 and "did not receive" any report. RN #2 stated Patient #1's name was not on Facility A's ED log because Patient #1 never came inside the facility. RN #2 stated the ED Physician told EMS to take the patient to Facility C.

During a telephone interview on 7/30/2025 at 6:08 PM, with Paramedic #1, Vice-President and Director of the EMS, stated the EMS truck that picked up Patient #1 from Facility B was a Basic Life Support (BLS) truck. He stated after the ambulance pulled in Facility A's ED Bay, the EMT driver went inside to use the bathroom and told the ED nursing staff they were getting a patient from Facility B. Paramedic #1 stated due to Facility A's ED close location from Facility B, the Advanced EMT in the back of the ambulance was busy and still taking the second set of vital signs on Patient #1. Paramedic #1 stated after the EMT driver used the bathroom she stopped at Facility A's ED nursing station and the staff told her the ED physician had decided to send Patient #1 to Facility C.

During a telephone interview on 7/30/2025 at 7:54 PM, with RN #3 she stated Patient #1 never came inside the [name of hospital] ED. She stated there was a phone call to Facility B. The ED Physician took over the phone and started talking to Facility B's House Supervisor.

During a telephone interview on 7/31/2025 at 10:10 AM, with the ED Physician, she stated one of the ED RNs said Facility B was sending Patient #1 to the ED. The ED Physician stated she thought Patient #1 needed to go to Facility C's ED due to the stroke like symptoms. The ED Physician stated she told Facility B's House Supervisor to call 911 if there was a problem with the patient. The ED Physician stated she never saw the patient. The ED physician stated she didn't know Patient #1 was in the EMS ambulance in Facility A's ED ambulance bay. The ED Physician stated she never received a report on the patient. She stated nurses were on the phone to Facility B and there was a lot of confusion in the communication. The ED physician stated she did not refuse to see Patient #1, but she did tell them to send Patient #1 to Facility C's ED.

During a telephone interview on 7/31/2025 at 10:38 AM, RN #4, who was Facility B's House Supervisor, stated on 7/22/2025, Patient #1 was transported to Facility C's ED. She stated she had just started her shift when Patient #1's elevated blood pressure was reported to her. Facility B's House Supervisor stated she intended to send Patient #1 next door to Facility A's ED to be seen as they normally do. However, Facility A's ED Physician called her and asked her why she was sending a pediatric patient to Facility A's ED. RN #4 stated she called the Administrator on Call for approval to send Patient #1 out to Facility C's ED since they normally don't transfer patients out of the health system.

During an interview on 7/31/2025 at 11:45 AM, Facility A's ED Manager stated there were no bells or alarms to alert nursing staff when an ambulance pulls into the ED ambulance bay. The ED Manager stated the EMT driver stopped at the nursing station but did not tell them the patient was in the back of the ambulance in the ambulance bay. The ED Nurse Manager did state the EMT driver told the nursing staff they were getting Patient #1 from Facility C.

In summary, Patient #1, a 16 year-old from a Behavioral facility (Facility B), was transferred to Facility A's ED with sudden onset of Hypertension, Headache and Brain Fog and did not receive a medical screening. During interview, Facility A's ED physician acknowledged the patient was not seen and she directed Patient #1 to be sent to Facility C.