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Based on review of medical records, policies and procedures and physician interview the facility failed to provide an appropriate medical screening examination that was within the capability of the hospital's emergency department including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for an individual who presented to the emergency department with complaint of pain at right arm fistula site for 1 (#6) of 25 sampled patients who presented to the emergency department. ~cross refer to 489.24 (a) (i) Medical Screening Examination- Tag A-2406.

Based on closed DED (Dedicated Emergency Department) medical record reviews, and physician interviews, the hospital failed to provide appropriate transfers by failing to: address all required aspects of transfer for 6 of 6 sampled patients (Patients # 13, 14, 15, 16, 18, and 21) presenting to the hospital's Dedicated Emergency Department (DED). ~cross refer to 489.24(e)(1)-(2), Appropriate Transfer - Tag A2409.

Based on review of medical records, policies and procedures and physician interview the facility failed to provide an appropriate medical screening examination that was within the capability of the hospital's emergency department including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for an individual who presented to the emergency department with complaint of pain at right arm fistula site for 1 (#6) of 25 sampled patients who presented to the emergency department.

Findings were:


Policy and Procedure
The facility's policy and procedure titled "Emergency Medical Condition and Active labor Policy" (EMTALA) Effective: August 1, 2011 was reviewed. The policy stated in part, "Policy/Purpose: To ensure compliance with special responsibilities of an emergency department ...which includes: Providing an appropriate MSE (Medical Screening Examination) ... I. Medical Screening Examination (MSE) : Medical Screening Exam is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not the individual has an emergency medical condition (EMC) or not." The scope of the MSE will be appropriate to the individual's signs and symptoms and the capability and capacity of the hospital. The MSE may range from a simple process involving only a brief H&P (history and physical) or as complex as multiple tests and diagnostic procedures."

Closed Medical Record Review Patient #6

Closed medical record review for Patient #6 revealed a 68 year old African American male that presented by ambulance to Hospital A's DED on 07/05/2016 at 0624, with a complaint of "Dialysis PT (patient), RT (right) arm pain." Review revealed vital signs on 07/05/2016 at 0626 were as follows: Blood Pressure (BP) 155/70 mmHg (millimeters of Mercury) (slightly elevated); Pulse (P) 79 BPM (Beats per Minute) (normal); Respirations (R) 16 RPM (Respirations per Minute) (normal); Temperature (T) 97.3° (degrees) F (Fahrenheit) (normal); and Pulse Oximetry (SpO2) 97 % (percent) Room Air (RA) (normal). Review of an Assessment, written by Registered Nurse (RN) #1 on 07/05/2016 at 0626, revealed, "...Pain Assessment Occurrence #1 Pain Intensity 10 (a pain scale of 0 to 10, where 0 represents no pain, and 10 represents the worst pain)..." Review revealed Medical Doctor (MD) #1 initiated a MSE on 07/05/2016 at 0625. Review of an ED Physician Note, written by MD #1 on 07/05/2016 at 0642, revealed, "...Chief Complaint: Pain at hemodialysis fistula (a surgically implanted access to allow dialysis). Patient presents to the emergency department nursing home (sic) with complaints of modest pain at his right upper extremity hemodialysis fistula site. Patient states he had this current fistula placed approximately 4 months ago, has been used for the past 3 weeks. He has had some discomfort during the sessions, yesterday the pain was moderate towards the end, patient requested they stop the session, they did in (sic) the session approximately 15 minutes early per his report. He states they did a study and said that there was a potential blockage proximally (situated close to) to the fistula site. He states he has had modest swelling without change since placement of the fistula. He currently has a let femoral dialysis catheter for backup. He has had multiple prior failed sites including the right groin, right neck, left upper extremity (sic). Patient states he was given an option to see the vascular center folks today while at dialysis yesterday, he thought that he may wish to see the VA (United States Department of Veterans Affairs) folks who have done all of his vascular work. His report there is fairly well, he did report discomfort in all of his veins throughout his whole body. Denies any systemic symptoms. No other complaints. He denies any arm numbness or tingling. Scant urine output noted. Patient has been receiving oxycodone (a pain medication) before dialysis sessions. History obtained from patient. Symptoms began: several weeks ago. Onset: gradual. Timing: Worse with dialysis, improves after session. Intensity: moderate, now mild. Aggravating factors: Dialysis. Review of Systems: All other systems negative as reviewed. CONSTITUTIONAL No ever, no chills. CARDIOVASCULAR No chest pain or syncope (passing out). RESPIRATORY No SOB (Shortness of Breath), no cough. GI (Gastrointestinal) No abdominal pain, no vomiting. GENITOURINARY scant uop (urine output). SKIN No rash or skin breakdown, chronic RUE (Right Upper Extremity) swelling since HD (Hemodialysis) fistula placed. NEUROLOGIC No headache, no arm numbness or tingling. MUSCULOSKELETAL right upper arm pain-improved. HEME (blood) + (positive) easy bruising / bleeding. Physical Exam CONSTITUTIONAL Vital signs reviewed, Alert and Oriented X (times) 3, nontoxic. NECK Graft site palpated, mild plethora (Flushing caused by dilation of superficial blood vessels). RESPIRATORY CHEST Chest is nontender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR RR (Rhythm Regular) with occasional extrasystole (extra beat), 2/6 systolic murmur, right upper extremity fistula with thrill. ABDOMEN Nontender, No masses, Bowel sounds normal, No distension. BACK There is no CVA (Costovertebral Angle) Tenderness, There is no tenderness to palpation, Normal inspection. UPPER EXTREMITY Inspection with left upper extremity fistula without thrill, no axillary (armpit) lesion. Right upper extremity with upper arm fistula with thrill, moderate swelling of right to left that patient states is stable. No hematoma, no skin warmth, no signs of skin infection, no bleeding from hemodialysis site. No axillary tenderness or swelling noted. Fourth and fifth fingers of the right hand with mild contractures. LOWER EXTREMITY Inspection with bilateral lower extremity stasis changes, left femoral PermCath (an implanted hemodialysis access) intact and nontender. NEURO Contractures of right upper extremity fourth and fifth fingers, otherwise motor and sensation intact to left upper extremity, speech normal. PSYCHIATRIC Anxious affect, fair insight... ED (Emergency Department) Course/Reassessment: Remains stable. No evidence of emergent condition. Patient with pain control in the emergency department. Case was discussed with nursing facility, vascular center follow-up at office next to hemodialysis center today as arranged by hemodialysis yesterday. Return to ER (Emergency Room) for red flag symptoms. Condition: Stable. Final Diagnosis: 1-Acute pain in hemodialysis graft site, 2-renal failure. Plan: Vascular Center follow up today as arranged by dialysis nurses. Return immediately if worse. Take routine medications as directed. Evaluation has revealed no signs of a dangerous process. Warned regarding possible red flag symptoms to watch out for, and need for close follow up. Understands verbal as well as written discharge instructions, is warned regarding their illness and prognosis, is able to repeat any risks, and is comfortable with plan and disposition. Has a clear mental status at this time and has clear judgment to make decisions regarding their care. Departure Condition: Stable..." Review revealed Patient #6 was administered Oxycodone / Acetaminophen (a pain medication) 5 mg (milligrams) / 325 mg, by mouth, on 07/05/2016 at 0702. Review of a Discharge Assessment, written by RN # 2 on 07/05/2016 at 0736, revealed, "...Pain Reassessment Pain Intensity 0 (no pain)... Discharge Disposition... Nurse Reported to (Named Nurse) Comments REPORT CALLED BY (Named Nurse), RN at 0655..." Review revealed Patient #6's vital signs on 07/05/2016 at 0736 were as follows: BP 152/74 mmHg (slightly elevated); P 82 BPM (normal); R 18 RPM (normal); T 97.5° F (normal); and SpO2 97 % RA (normal). Review revealed Patient #6 was discharged from Hospital A's DED on 07/05/2016 at 0738, by ambulance, back to his nursing home.

Physician interview, conducted with MD #1 on 08/30/2016 at 1425, revealed Patient #6 complained of arm pain, and was treated for the complaint. Interview revealed Patient #6 was given pain medication, and reported being pain free at the time of discharge. Interview revealed Patient #6 already had an appointment scheduled with a vascular access center for issues related to his dialysis access. Interview revealed the vascular access center would be where he could receive definitive treatment for any potential blockage of his dialysis access. Interview revealed there was no further treatment available at Hospital A, and MD #1 felt comfortable with a discharge disposition back to the nursing home, because Patient #6 already had his vascular access appointment scheduled. Interview revealed the Medical Screening Exam was completed, and Patient #6 was alert and oriented, and stable at the time of discharge.


The facility failed to ensure that on July 5, 2016 ancillary services (ultra sound) were provided for Patient #6 that were available and within the capability of the hospital to confirm or deny the prior finding of a possible blockage proximal to the right arm fistula. As this resulted in an inappropriate/inadequate medical screening examination.

Based on closed DED (Dedicated Emergency Department) medical record reviews, policy and procedure, and physician interviews, the hospital failed to provide appropriate transfer by failing to: address all required aspects of transfer for 6 of 6 sampled patients (Patients # 13, 14, 15, 16, 18, and 21) presenting to the hospital's Dedicated Emergency Department (DED).

The findings include:

1. Closed medical record review for Patient #13 revealed a 69 year old Caucasian male that presented by ambulance to Hospital A's DED on 08/13/2016 at 1011, with a complaint of "Fall." Review of an ED Physician Note, written by Physician's Assistant (PA) #1 on 08/13/2016 at 1100, revealed, "...Chief Complaint: The patient is a resident of (Named Facility) assisted living. He has a history of Parkinson's and dementia (neurological conditions). Today he was walking out of his room and tripped and fell. He bumped his head on the floor. He has a large laceration on his right eyebrow and left eyelid. Patient denies loss of consciousness. No headache. No nausea or vomiting..." Review of a Head CT (Computerized Tomography) scan report, written by MD #2 on 08/13/2016 at 1115, revealed, "...Impression: 1. Cortical increased density in the left parietal region that is concerning for acute parenchymal hemorrhage..." Review revealed Patient #13 was transferred to another hospital by ambulance, on 08/13/2016 at 1425. Review of a Certification for Transfer form revealed, "I hereby certify that based upon reasonable risks and benefits to the patient, and based upon the information available at the time of the patient's medical screening and examination, the medical benefits reasonably expected from the provisions of appropriate medical treatment at another facility outweigh the increased risks, if any, to the individual's medical condition from affecting the transfer. Reason for transfer: Medically indicated, Based on risks and benefits... The benefits relied upon for the transfer is: See above... Specialized services/procedures at receiving facility... The risks of transfer are: MVC (Motor Vehicle Collision), death. Transportation risks, which include traffic delays, accidents during transport inclement weather, rough terrain or turbulence, limitation of equipment and personnel in transport. Deterioration in patient condition which includes a potential threat to the health and possible survival of the patient... Transferring Physician's Signature: (Signed by PA #1) Date/Time: 08/13/2016 1315..." Review revealed no patient specific risks of transfer, and no physician co-signature for physician certification for transport.

Telephone interview conducted with the DED Medical Director on 08/31/2016 at 0900, revealed Physician co-signature for a Physician's Assistant to arrange a patient transfer is currently not required, however Physicians are available for midlevel providers at all times. Interview revealed patient specific risks and benefits are expected to be provided prior to transferring a patient.

2. Closed medical record review for Patient #14 revealed a 27 year old African American female that presented to Hospital A's DED on 08/03/2016 at 1532, with a complaint of "Is not her normal self / Don't Half Talk (sic)." Review of an ED Physician Note, written by MD #1 on 08/03/2016 at 0829, revealed, "...Patient presents to the emergency department from home with her mother who brought her in with complaints of patient won't talk and hasn't for the past several weeks... Patient does have a history of anxiety disorder and psychiatric illness, she was admitted to (Named Facility) earlier this year for several weeks... Patient refusing to speak in emergency department... Plan: Will need ongoing evaluation and treatment in psych (psychiatric) hospital setting..." Review revealed Patient #14 was transferred to an inpatient psychiatric facility by law enforcement on 08/05/2016 at 1415. Review of a Certification for Transfer form revealed, "I hereby certify that based upon reasonable risks and benefits to the patient, and based upon the information available at the time of the patient's medical screening and examination, the medical benefits reasonably expected from the provisions of appropriate medical treatment at another facility outweigh the increased risks, if any, to the individual's medical condition from affecting the transfer... The risk of transfer are: MVC. Transportation risks, which include traffic accidents during transport inclement weather, rough terrain or turbulence, limitation of equipment and personnel in transport... Transferring Physician's Signature: (Signed by MD #3) Date/Time: 08/06/2016 (no time provided)..."

Telephone interview conducted with the DED Medical Director on 08/31/2016 at 0900, revealed patient specific risks and benefits are expected to be provided prior to transferring a patient. Interview revealed a time should be provided for physician certification for transport.

3. Closed medical record review for Patient #15 revealed a 53 year old African American male that presented to Hospital A's DED on 03/25/2016 at 2304, with a complaint of "Stabbed in the face." Review of an ED Physician Note, written by MD #1 on 08/03/2016 at 0829, revealed, "...Patient in a home invasion. Patient hit in the head with a iron jack with stabbing the face right jaw and throat with a knife (sic). No fever no chills. Patient has been drinking. Patient past history is for arthritis only per patient... Last tetanus unknown. Denies any allergies. He is alert and oriented. He has a headache. No no (sic) loss of consciousness per patient. He has chemical burns on his face neck on the chest (sic) from incident 2 years ago spraying cotton..." Review revealed Patient #15 was transferred to another hospital on 03/26/2016 at 0100. Review of a Certification for Transfer form revealed, "I hereby certify that based upon reasonable risks and benefits to the patient, and based upon the information available at the time of the patient's medical screening and examination, the medical benefits reasonably expected from the provisions of appropriate medical treatment at another facility outweigh the increased risks, if any, to the individual's medical condition from affecting the transfer... The risks of transfer are: See below. Transportation risks, which include traffic delays, accidents during transport inclement weather, rough terrain or turbulence, limitation of equipment and personnel in transport. Deterioration in patient condition which includes a potential threat to the health and possible survival of the patient... Transferring Physician's Signature: (Signed by MD #1) Date/Time: 03/26/2016 0015"

Telephone interview conducted with the DED Medical Director on 08/31/2016 at 0900, revealed patient specific risks are expected to be provided prior to transferring a patient. Interview revealed a time should be provided for physician certification for transport.

4. Closed medical record review for Patient #16 revealed a 59 year old Caucasian male that presented to Hospital A ' s DED on 05/06/2016 at 1403, with a complaint of "STEMI (S T Elevation Myocardial Infarction [a heart attack])." Review of an ED Physician Note, written
by the DED Medical Director on 08/03/2016 at 0829, revealed, "...EMS (Emergency Medical Services) called for STEMI, inferior STEMI, cardiac arrest on way (sic) with first torsades and then V tach (potentially lethal heart rhythms), CPR (Cardiopulmonary Resuscitation) x 4 minutes then shocked, patient woke up and went to normal sinus rhythm..." Review revealed Patient #16 was transferred to another hospital on 05/06/2016 at 1450. Review of a Certification for Transfer form revealed, "I hereby certify that based upon reasonable risks and benefits to the patient, and based upon the information available at the time of the patient's medical screening and examination, the medical benefits reasonably expected from the provisions of appropriate medical treatment at another facility outweigh the increased risks, if any, to the individual's medical condition from affecting the transfer... The risks of transfer are: MVC. Transportation risks, which include traffic delays, accidents during transport inclement weather, rough terrain or turbulence, limitation of equipment and personnel in transport. Deterioration in patient condition which includes a potential threat to the health and possible survival of the patient... Transferring Physician's Signature: (Signed by the DED Medical Director) Date/Time: 05/06/2016 (no time provided)..."

Telephone interview conducted with the DED Medical Director on 08/31/2016 at 0900, revealed patient specific risks are expected to be provided prior to transferring a patient. Interview revealed a time should be provided for physician certification for transport.


5. Closed medical record review for Patient #18 revealed a 13 year old Caucasian male that presented to Hospital A's DED on 05/22/2016 at 1434, with a complaint of "Broke Left Arm." Review of an ED Physician Note, written by PA #3 on 05/22/2016 at 1549, revealed, "...Patient is a 13-year-old presenting to the emergency department with a chief complaint of 'broken left arm.' The patient reports he was running and fell backward catching himself on his bilateral upper extremities and buttock. He is now complaining of pain in the left wrist only. Denies hitting his head or any neck pain, denies loss of consciousness. Obvious swelling and deformity... to the left arm..." Review revealed Patient #18 was transferred to another hospital on 05/22/2016 at 1600. Review of a Certification for Transfer form revealed, "I hereby certify that based upon reasonable risks and benefits to the patient, and based upon the information available at the time of the patient's medical screening and examination, the medical benefits reasonably expected from the provisions of appropriate medical treatment at another facility outweigh the increased risks, if any, to the individual's medical condition from affecting the transfer... The risks of transfer are: MVA (Motor Vehicle Accident). Transportation risks, which include traffic delays, accidents during transport inclement weather, rough terrain or turbulence, limitation of equipment and personnel in transport. Deterioration in patient condition which includes a potential threat to the health and possible survival of the patient... Transferring Physician's Signature: (Signed by PA #3) Date/Time: 05/22 3:47 pm (afternoon)..."

Telephone interview conducted with the DED Medical Director on 08/31/2016 at 0900, revealed Physician co-signature for a Physician's Assistant to arrange a patient transfer is currently not required, however Physicians are available for midlevel providers at all times. Interview revealed patient specific risks and benefits are expected to be provided prior to transferring a patient.

6. Closed medical record review for Patient #21 revealed a 62 year old African American female that presented to Hospital A's DED on 05/16/2016 at 0128, with a complaint of "Bleeding from shunt." Review of an ED Physician Note, written by PA #4 on 05/16/2016 at 0341, revealed, "...Patient was transported via EMS from home due to actively bleeding fistula. Pt was discharged from (Named Facility) 2 hours ago for the same complaint. At that time bleeding from fistula site subsided with applying Surgicel (a product designed to help stop bleeding) and multiple dressings/ace wrap... Pt was d/c (discharged) w/o (without) incident. Pt arrived home and per daughter, was lying down watching TV (television) when site began to bleed. Daughter states the thick dressing was fully saturated within minutes. EMS was contacted at that time. EMS placed new dressing w/ (with) bleeding controlled at this time. Pt states she is 'cold' and states hip pain but denies any other symptoms... " Review revealed Patient #21 was transferred to another hospital on 05/16/2016 at 0520. Review of a Certification for Transfer form revealed, "I hereby certify that based upon reasonable risks and benefits to the patient, and based upon the information available at the time of the patient's medical screening and examination, the medical benefits reasonably expected from the provisions of appropriate medical treatment at another facility outweigh the increased risks, if any, to the individual's medical condition from affecting the transfer... The risks of transfer are: MVC, death. Transportation risks, which include traffic delays, accidents during transport inclement weather, rough terrain or turbulence, limitation of equipment and personnel in transport. Deterioration in patient condition which includes a potential threat to the health and possible survival of the patient... Transferring Physician's Signature: (Signed by PA #4) Date/Time: 5/16/16 0325... Level of Medical Assistance for Transport: (none specified)..."

Telephone interview conducted with the DED Medical Director on 08/31/2016 at 0900, revealed Physician co-signature for a Physician's Assistant to arrange a patient transfer is currently not required, however Physicians are available for midlevel providers at all times. Interview revealed patient specific risks and benefits are expected to be provided prior to transferring a patient.


The facility's policy and procedure titled "Emergency Medical Condition and Active labor Policy" (EMTALA) Effective: August 1, 2011 was reviewed. The policy stated in part, II Stabilize... Is an appropriate transfer as defined below...Individual (or legally responsible individual) requests transfer after being informed of the hospital's obligation and risks. Transfer request must be in writing, indicate reason for request and indicate they are aware of the risks and benefits..."


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