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Based on review of facility documentation, non-hospital ambulance transport log documentation, recipient/second hospital medical record (MR) review, and staff interviews (EMP), it was determined the facility failed to comply with 489.24 related to Medical Screening Examination.

Findings include:

The review of facility documentation, non-hospital ambulance transport log documentation, recipient hospital medical record (MR) review, and staff interviews (EMP) revealed the facility failed to ensure an appropriate medical screening examination (MSE) to a patient who was on hospital property was completed in one of 21 medical records reviewed.

Cross reference with:
489.24(a) and 489.24(c) - Medical Screening Exam

Based on review of facility documentation, the non-hospital ambulance transport log documentation (MR1), the recipient/second hospital medical record (MR1), and staff (EMP) interview, it was determined the facility failed to provide an appropriate medical screening examination for one of 21 medical records reviewed (MR1).

Findings include:

Review with EMP1 on March 22, 2023, at 0948, of the voice recordings between emergency medical services (EMS) and Evangelical Community Hospital staff revealed there were three recordings of phone calls related to MR1.

The first call took place on March 16, 2023, at 0826 between EMS and EMP10. The first call identified the name of the non-hospital ambulance calling to provide hospital notification regarding MR1. The phone call was cut off.

The second call took place on March 16, 2023, at 0829, between EMS and EMP11. A full report was provided regarding MR1. The estimated time of arrival (ETA) was 10 minutes.

The third call took place on March 16, 2023, at 0838. EMP7 identified self to EMS and stated that (s/he) understood they had a 21-week pregnant patient involved in a motor vehicle collision (MVC) with abdominal pain. EMP7 stated the patient needed to go to a trauma center. EMS responded they were pulling into the house (meaning hospital), and the patient wanted to come here. EMP7 stated it was completely inappropriate, and this would be a transfer, as s/he (EMP7) could not clear a pregnant woman with abdominal pain following an MVC. EMS asked EMP7 if s/he wanted EMS to take the patient to (name of another town). EMP7 stated (s/he) didn't know what the protocol was since EMS was backing in here (into the ED). S/he stated you do what you need to do, but you need to know that this is inappropriate. EMS responded OK, just hold on (there was inaudible discussion between EMS) then the call ended.

Review on March 22, 2023, at 1030, with EMP6 of the security video footage identified as the ambulance bay exterior revealed the identified ambulance arrived on March 16, 2023, timestamp at 0829, on hospital grounds at curb of ED ambulance entrance, sits there and leaves at timestamp March 16, 2023, at 0832.

Interview with EMP6 on March 22, 2023, at 1035 confirmed the spot where the ambulance parked was on hospital grounds and within approximately 100 feet from the ambulance bay entrance.

Interview with EMP7 on March 22, 2023, at 1140, confirmed EMP7 had EMTALA (Emergency Medical Treatment and Labor Act) training in the past. EMP7 described the phone call with EMS from March 16, 2023 related a 21-week pregnant patient involved in an MVC. EMP7 related that EMS called and spoke with the ED charge nurse. EMP7 called them back to say the patient should go to a trauma center since she was pregnant. EMP7 noted that EMS said they were pulling in, and was not sure whether that meant they were onsite or nearby. EMP7 stated EMS made a unilateral decision to leave. Explained to EMP7 that the voice recordings were reviewed and reflected that EMP7 was aware the non-hospital ambulance was backing up to the hospital's ED ambulance entrance.

Interview with EMP4 on March 22, 2023, at 1215 confirmed there was no medical record at Evangelical Community Hospital for this patient.

Interview with EMP1 on March 22, 2023, at 1425 confirmed there was no copy of the EMS trip log on-site. EMP1 stated the non-ambulance hospital transport company refused to release a copy to Evangelical Community Hospital, as they did not see the patient. EMP1 stated the non-ambulance hospital transport company would release a copy directly to the Department of Health.

Review of the non-hospital ambulance transport log revealed the following documentation for March 16, 2023. MR1 was transported from the scene of an MVC by a non-hospital ambulance. MR1 was a 21-week pregnant patient with moderate lower abdominal pain after an MVC. Vital signs were stable. Documentation reflected the ambulance crew was enroute and noted the patient's obstetrical/gynecologic physician (OB/GYN) was located at Evangelical Community Hospital. The Emergency Department (ED) at Evangelical was the appropriate and closest receiving facility. Pre-hospital notification attempts revealed one unsuccessful call due to the cellular service. A second call was made by the non-hospital ambulance to Evangelical Community Hospital ED staff (EMP11) with an update of MR1's condition and notification they were enroute. At 0829 upon arriving at Evangelical ED the EMS crew was radioed by 911 that Evangelical was requesting to be called. At 0830 EMS crew called Evangelical and spoke with ED staff (EMP7) who stated to EMS that (s/he) knew they were arriving. EMP7 stated the patient had to be diverted to (name of another hospital ED), as this patient was totally inappropriate to be brought to Evangelical ED, and they were not suited to care for the patient due to her pregnancy.

Review of the second hospital's medical record for MR1 revealed the following documentation for March 16, 2023. MR1 was transported by ambulance to the ED at the second hospital. MR1 was provided a medical screening examination and OB/GYN work up. It was determined the mother and baby were stable for discharge to home. The EMS transfer of care record from the second hospital documented MR1's symptoms and vital signs. There was no documentation that EMS stopped at another hospital ED before continuing to the second hospital.

Review on March 22, 2023, of Evangelical Community Hospital policy "EMTALA," last reviewed by the facility September 7, 2022, revealed " ... POLICY It is the policy of Evangelical Community Hospital and its subsidiaries to comply with all applicable requirements of the Emergency Medical Treatment and Labor Act (" EMTALA "), a federal law requiring a Medicare participating hospital with a dedicated emergency department to provide a medical screening examination ("MSE") to any individual who comes to the emergency department and requests such an examination regardless of his/her ability to pay or insurance coverage status. EMTALA prohibits such hospital from refusing the MSE and, if the individual has an emergency medical condition ("EMC"), the Hospital must provide appropriate stabilizing treatment or appropriate transfer of such individual to another facility ...PROCEDURE.... 3. Medical Screening Examination a) The Hospital shall provide a medical screening examination to any individual who "comes to the Emergency Department". b) The medical screening examination is the examination of the patient by the Qualified Medical Person required to determine within reasonable clinical confidence whether an emergency medical condition does or does not exist. The examination should be tailored to the patient ' s complaint and presenting symptoms and may involve performing ancillary studies and procedures.... 5. Individuals Who Have An Emergency Medical Condition If, after a medical screening, it is determined that an individual has an emergency medical condition, the Hospital shall: a) Within the capability and capacity of the staff and facilities available at the Hospital (including coverage available through the Hospital's on-call roster), provide treatment necessary to stabilize the individual, at which time the individual may be discharged; or b) Admit the individual to the Hospital in order to stabilize the individual; or c) If stabilization of the individual is beyond the capabilities or capacity of the Hospital, arrange for appropriate transfer of the individual to another medical facility in accordance with this policy. d) Obstetric patients with significant trauma will be seen in the emergency department. Cardiotocographic monitoring requires OB/GYN consult. Non-trauma obstetrics patients who are (greater than or equal to) 20 weeks gestation presenting with pregnancy related complaints may be sent to Labor & Delivery for a medical screening examination. ...11. Ambulances i. Under community wide emergency medical service (EMS) protocols that direct transport to a hospital other than the hospital that owns the ambulance. The individual is considered to have "come to the emergency department" of the hospital to which the individual is transported, at the time the individual is brought onto that hospital's property ... "

Review on March 22, 2023, at 1450, of the on-call physician logs revealed there was an OB/GYN physician on-call on March 16, 2023, for Evangelical Community Hospital.

Based on review of facility documentation and staff (EMP) interview, it was determined the facility failed to provide the necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital for an emergency medical condition for one of 21 medical records reviewed (MR1).

Findings include:

Review on March 22, 2023, of Evangelical Community Hospital policy "EMTALA," last reviewed by the facility September 7, 2022, revealed " ... POLICY It is the policy of Evangelical Community Hospital and its subsidiaries to comply with all applicable requirements of the Emergency Medical Treatment and Labor Act (" EMTALA "), a federal law requiring a Medicare participating hospital with a dedicated emergency department to provide a medical screening examination ("MSE") to any individual who comes to the emergency department and requests such an examination regardless of his/her ability to pay or insurance coverage status. EMTALA prohibits such hospital from refusing the MSE and, if the individual has an emergency medical condition ("EMC"), the Hospital must provide appropriate stabilizing treatment or appropriate transfer of such individual to another facility ...PROCEDURE.... 3. Medical Screening Examination a) The Hospital shall provide a medical screening examination to any individual who "comes to the Emergency Department". b) The medical screening examination is the examination of the patient by the Qualified Medical Person required to determine within reasonable clinical confidence whether an emergency medical condition does or does not exist. The examination should be tailored to the patient ' s complaint and presenting symptoms and may involve performing ancillary studies and procedures.... 5. Individuals Who Have An Emergency Medical Condition If, after a medical screening, it is determined that an individual has an emergency medical condition, the Hospital shall: a) Within the capability and capacity of the staff and facilities available at the Hospital (including coverage available through the Hospital's on-call roster), provide treatment necessary to stabilize the individual, at which time the individual may be discharged; or b) Admit the individual to the Hospital in order to stabilize the individual; or c) If stabilization of the individual is beyond the capabilities or capacity of the Hospital, arrange for appropriate transfer of the individual to another medical facility in accordance with this policy. d) Obstetric patients with significant trauma will be seen in the emergency department. Cardiotocographic monitoring requires OB/GYN consult. Non-trauma obstetrics patients who are (greater than or equal to) 20 weeks gestation presenting with pregnancy related complaints may be sent to Labor & Delivery for a medical screening examination. ...11. Ambulances i. Under community wide emergency medical service (EMS) protocols that direct transport to a hospital other than the hospital that owns the ambulance. The individual is considered to have "come to the emergency department" of the hospital to which the individual is transported, at the time the individual is brought onto that hospital's property ... "

Review with EMP1 on March 22, 2023, at 0948, of the voice recordings between emergency medical services (EMS) and Evangelical Community Hospital staff revealed there were three recordings of phone calls related to MR1.

The first call took place on March 16, 2023, at 0826 between EMS and EMP10. The first call identified the name of the non-hospital ambulance calling to provide hospital notification regarding MR1. The phone call was cut off.

The second call took place on March 16, 2023, at 0829, between EMS and EMP11. A full report was provided regarding MR1. The estimated time of arrival (ETA) was 10 minutes.

The third call took place on March 16, 2023, at 0838. EMP7 identified self to EMS and stated that (s/he) understood they had a 21-week pregnant patient involved in a motor vehicle collision (MVC) with abdominal pain. EMP7 stated the patient needed to go to a trauma center. EMS responded they were pulling into the house (meaning hospital), and the patient wanted to come here. EMP7 stated it was completely inappropriate, and this would be a transfer, as s/he (EMP7) could not clear a pregnant woman with abdominal pain following an MVC. EMS asked EMP7 if s/he wanted EMS to take the patient to (name of another town). EMP7 stated (s/he) didn't know what the protocol was since EMS was backing in here (into the ED). S/he stated you do what you need to do, but you need to know that this is inappropriate. EMS responded OK, just hold on (there was inaudible discussion between EMS) then the call ended.

Review on March 22, 2023, at 1030, with EMP6 of the security video footage identified as the ambulance bay exterior revealed the identified ambulance arrived on March 16, 2023, timestamp at 0829, on hospital grounds at the curb of the ED ambulance entrance, sat there and left on March 16, 2023, timestamp at 0832.

Interview with EMP6 on March 22, 2023, at 1035 confirmed the spot where the ambulance parked was on hospital grounds and within approximately 100 feet from the ambulance bay entrance.

Interview with EMP7 on March 22, 2023, at 1140, confirmed EMP7 had EMTALA (Emergency Medical Treatment and Labor Act) training in the past. EMP7 described the phone call with EMS from March 16, 2023, related a 21-week pregnant patient involved in an MVC. EMP7 related that EMS called and spoke with the ED charge nurse. EMP7 called them back to say the patient should go to a trauma center since she was pregnant. EMP7 noted that EMS said they were pulling in and was not sure whether that meant they were onsite or nearby. EMP7 stated EMS made a unilateral decision to leave. Explained to EMP7 that the voice recordings were reviewed and reflected that EMP7 was aware the non-hospital ambulance was backing up to the hospital's ED ambulance entrance.

Interview with EMP11 on March 22, 2023, at 1225 revealed s/he recalled taking report from EMS on the incoming 21-week pregnant patient involved in a motor vehicle accident. EMS stated the patient's vital signs were stable and would arrive in about 10 minutes. EMP11 stated they gave the physician a heads up (EMP7). EMP7 told EMP11 to call the ambulance back and tell them not to come. EMP11 stated they did not feel comfortable with this and spoke with their supervisor, EMP4. EMP4 related that EMP7 would need to make that call to EMS, not the nurse. EMP11 called the ambulance stating EMP7 wanted to speak to EMS. EMP11 stated s/he recalled EMP7 saying that the ambulance could not bring the patient to the hospital. EMP11 stated they overheard EMP7 make a statement about the ambulance backing in. EMP11 related that a paramedic bystander was in the process of leaving and witnessed the ambulance on the property and then pull out and told EMP11 about it. EMP11 immediately reported it to his/her supervisor, EMP4.

Interview with EMP4 on March 22, 2023, at 1235 revealed EMP4 acknowledged being made aware of the event. EMP4 immediately filled out an incident report related to it. EMP4 related the incident reporting ensures risk/administration were aware of the incident.

Review on March 22, 2023, at 1450, of the on-call physician logs revealed there was an OB/GYN physician on-call on March 16, 2023, for Evangelical Community Hospital.

Cross reference:
489.24 - 489.20(l) Compliance
489.24(a) and 489.24(c) - Medical Screening Exam