HospitalInspections.org

Based on interview, observation, and record review the facility was found not in compliance with the Emergency Medical Treatment and Labor Act (EMTALA) by failing to perform adequate testing within their capabilities.

The findings are:

A. The facility failed to perform adequate testing within their capabilities. Refer to Tag 2409

Based on record review and interview the facility failed to perform a medical screening exam within the hospitals capability for 3 (P[patient]1, P11, P12) out of 20 (P1-P20) patients that were reviewed for requesting emergency medical care. This deficient practice led to a delay in care for the patient and lead the patient to seek care at another hospital.

The findings are:

A. Record review of facility policy titled, "FSED [Free-standing Emergency Department] Scope of Services" dated 10/26/2017 stated under "Purpose: It is the [Name of Facility] Freestanding Emergency Department (FSED) commitment to provide quality emergency care to patients of all ages within our community and regional service area. The [Name of Facility] FSED consist of an experienced team of medical professionals trained in emergency care available 365 day- a year, 24 hours a day, 7 days a week. The FSED is an off-campus emergency department from the main [Name of Facility - main] hospital. It is established as and designated as an integrated department of the [Name of Facility - main] hospital. The [Name of Facility] Freestanding Emergency Department is a comprehensive; 10-bed emergency facility that provides a range of health care services including emergency care services, diagnostic imaging, blood bank, respiratory and laboratory services. Our health care professionals create a place of healing and caring for patients and families in the community seeking emergency services." Under "Services: Free Standing Emergency Department services include but are not limited to: . . . Advanced Imaging and Diagnostic: provide 24 hour service - 64 slice Computed Tomography (CT) - Ultrasound (OB/GYN, Vascular and Abdominal) - Digital Diagnostic Imaging. . . Patients of the FSED who require further treatment or care will have access to the services provided at the main hospital campus of [Name of Facility]. . . Patients requiring a longer stay, observation or inpatient admission, will be transported via ambulance to the main hospital campus."

B. Record review of facility policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Policy" dated 02/05/2021, on page 7 under "Individuals Presenting to Off-Campus Departments" it states, ". . . If a decision is made to move or transfer an individual from the off-campus department, ED [emergency department] staff shall assist in arranging such movement or transfer in accordance with appropriate hospital procedures regarding transport and transfer of patients." An attachment titled, "Patient Refusal of Appropriate Transportation Scenarios Guidance Document" stated, "The disposition of the patient should be indicated as Transferred and should never be indicated as "discharged." Hospital ED staff should contact the receiving hospital, advise them that the patient may be arriving by private vehicle, and provide the pertinent clinical information regarding the patient's EMC [Emergency Medical Condition]."

C. Record review of P1's electronic health record revealed:

1. Review of note titled, "ED [Emergency Department] Physician Documentation" with an arrival date of 04/23/2023 on page 1, the history of present illness at 1630 (4:30 PM) stated, "Patient presents to ED today with left leg pain." On page 2 it stated, "ED Course: Norco [pain medication] was given for pain and patient was explained that he needs urgent CT scan as patient had a major vascular surgery [surgery involving arteries or veins] and complains of pain in the same area today. [Patient] was explained that I am not able to scan him as our scanner is down. Patient then stated he is willing to sign out AMA [Against Medical Advice] and called for a ride and [sic] go to a facility in order to get the CT scan done. pt [Patient] was explained that he needs to be seen in the ED after getting discharge from here to get the ct [sic] scan done to r/o [rule out] complications of the procedure. Pt left ED in stable condition."

2. Review of note titled, "ED Nurse Documentation" on page 3 under "Outcome" it stated "Patient left the ED." The time stamp is 1718 (5:18 PM) on 04/23/2023.

3. Review of outside facility records revealed:

a. Patient face sheet revealed that patient presented to their ED on 04/23/2023 at 1751 (5:51 PM) with an admit reason of "Exetreme [sic] Pain Leg."

b. Physician ED note revealed a chief complaint that stated, "Pt has hx [history] of fem pop bypass [rerouting of the femoral and popliteal arteries in the leg] s/p [status post] gunshot wound in 2017, has been having pain to that left leg since. Reports pain worse the past 6 months. Went to [facility name] ER [Emergency Room] and told that their CT was down and he needed to come to another facility." On page 2 under "Medical Decision Making" it stated, "Patient presents with possible acute arterial thrombosis [blood clot in the artery] or graft thrombosis [blood clot at site of graft] from his previous arterial graft [damaged or diseased artery replaced with a healthy vessel]. An emergent ultrasound of the left lower extremity will be ordered. . . Emergent call was placed to our vascular surgeon."

4. Review of records did not reveal documentation that patient was offered an ambulance for transfer to the main campus.

D. Record review of P11's electronic health record revealed:

1. Review of note titled, "ED Physician Documentation" with an arrival date/time of 04/23/2023 at 12:32 PM, on page 1 the history of
present illness states, "Patient presents to ED today with chief complaint of left upper quadrant pan, states pain started 2 weeks ago but acutely worsened today when he was lifting boxes. . ." On page 2 the "ED Course" at 12:59 PM states, ". . . Patient was explained that he definitely needs a CT abdomen and pelvis with contrast however I am not able to scan him as our scanner is down and that he would need to be transferred to the main hospital in order to complete the workup. Patient was offered blood work. Patient stated he is afraid of needles and he would rather get the lab work done in the main hospital rather than getting stuck twice. Patient declined the blood work and willing to sign out AMA."

2. Review of note titled, ED Nurse Documentation" on page 2 under "Outcome" it states, "Patient left the ED." The time stamp is 1331 (1:31 PM) on 04/23/23.

3. Review of note titled, "ED Physician Documentation" with an arrival date/time of 04/23/2023 at 1:37 PM, on page 1 the history of present illness states, "This [age and gender] present to ED via POV [privately owned vehicle] with complaints of chest - sent from FSED for CT. Patient presents with chest pain. Pain is left sided. He thinks the pain may have started in the LLQ [left lower quadrant of abdomen] and traveled up into his chest. He reports associated nausea [feeling like throwing up and SOB [shortness of breath]." On page 3 at 1918 (7:18 PM) it states, "Physician consultation: [name of doctor] and will see patient in ED, would like admission per Dr. hospitalist [sic]." On page 4 it states, "Disposition Summary: 04/23/23 1930 [7:30 PM] Hospitalization Ordered - Hospitalization Status: Inpatient Admission."

4. Review of records did not reveal documentation that patient was offered an ambulance for transfer to the main campus and patient did not sign a refusal of transportation, opting for POV for transfer to the main campus.

D. Record review of P12's electronic health record revealed:

1. Review of note titled, "ED Physician Documentation" with an arrival date/time of 04/23/2023 at 2:07 PM, on page 1 the history of present illness at 1447 (2:47 PM) states, "Patient presents to ED today with chief complaint of lower abdominal pain. . ." On page 2 the "ED Course" at 1450 (2:50 PM) states, ". . . ultrasound ordered to rule out appendicitis. Patient was explained that she would need a transfer to the main hospital to get a CT scan if the ultrasound appendix does not show any appendicitis." The "ED Course" at 1650 (4:50 PM) states, ". . . ultrasound not able to visualize appendix and does have some noncompressible bowel (finding that may indicate an obstruction) that was seen which could be likely due to colitis or some inflammation of that sort. Patient needs a CT scan, on reassessment patient's pain has improved and she is willing to go to the Mountain View main hospital to complete the workup getting CT abdomen and pelvis. Patient states the pain has improved on reassessment. Report was given to [MD name] in the ED. patient left the ED in stable condition." The patients "Disposition Summary" at 1652 (4:52 PM) states "Transfer Ordered - Transfer Location: [main hospital site name]".

2. Review of note titled, "ED Nurse Documentation" dated 04/23/2023 on page 3 under, "Outcome" at 1540 (3:40 PM) it states, "Discharged to home ambulatory." At 1652 (4:52 PM) it states, "ER care complete, transfer ordered by MD." At 1704 (5:04 PM) it states "Patient left the ED."

3. Review of note titled, "ED Physician Documentation" with an arrival date/time of 04/23/2023 at 5:27 PM, on page 1 the history of present illness at 1746 (5:46 PM) states, "Patient is a [age and gender of patient] transferred from the free-standing ER for a CT of her abdomen. . ." On page 2 the "ED Course" at 1948 (7:48 PM) states, "Patient is resting comfortably and is currently asymptomatic. CT scan showed nonspecific enteritis. Patient does not have nausea, diarrhea, fever. Based on these findings patient is to be discharged home. It is recommended that she follow-up with her primary care provider for further evaluation. . ."

4. Review of records did not reveal documentation that patient was offered an ambulance for transfer to the main campus and patient did not sign a refusal of transportation, opting for POV for transfer to the main campus.

E. During an interview with S14, RN (Registered Nurse) on 06/21/2023 at 8:30 AM it was asked if there was a protocol in place when imaging machines are down at the free-standing ED? It was explained that they would do what they could for example, get their labs and then transfer to the main hospital.

F. During an interview with S11, MD (Medical Doctor) on 06/22/2023 at 11:15 AM it was asked what the process was when the CT scanner is down at the free-standing ED. It was explained that if a patient needs a CT they would be transferred to the main hospital. They would get bloodwork, give the physician at main a call and setup the transfer. It was asked if patients were ever advised to leave AMA, it was stated that they do not, they just present the options to the patient.