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Based on interviews, observation and policy review, the facility failed to comply with 489.24 (A2406) by failing to provide an appropriate medical screening examination for a patient who presented to the Emergency Department.. The cumulative effect of this systemic practice resulted in the facility's inability to ensure that all patients presenting to the Emergency Department would receive a medical screening exam. The average monthly census of the Emergency Department is 2,424 patients.

Based on interviews, medical record review and policy review, the facility failed to provide a medical screening examination for one (Patient #21) of 20 medical records reviewed. The average monthly census of the Emergency Department is 2,424 patients.


Findings include:


Facility A's Medical Staff Coverage of the Emergency Department policy was reviewed. The policy stated the emergency department physician will see all patients arriving in the emergency department unless the patient refuses examination or the private attending physician chooses to treat the patient through prior arrangements or at the request of the patient.

Facility A's Triage and Care of the Emergency Department Patient policy was reviewed. The policy stated every patient presenting to the Emergency Department is rapidly assessed by the registered nurse and seen by the emergency department physician/provider.

Facility A's ED "Full Capacity" guidelines and Diversion Policy was reviewed. The policy stated any ambulance arriving in the emergency department with a patient for treatment during diversion will be evaluated.


1. On 10/04/16 at 1:19 PM, EMS (Emergency Medical Service) Staff K was interviewed via telephone regarding the alleged EMTALA violation. EMS Staff K reported remembering Patient #21 from 09/25/16. EMS Staff K stated he/she told the nurse in the Emergency Department at Facility A that EMS Staff K was "in the parking lot at your back door". EMS Staff K reported the nurse in the Emergency Department at Facility A responded by saying "we want you to divert". Non-Staff K restated Facility A's nurse knew the ambulance was at Facility A's back door.

2. On 10/04/16 at 3:19 PM, Staff J was interviewed. Staff J reported remembering the event involving Patient #21 "well". Staff J stated he/she was sitting behind the nurse and was able to overhear the conversation between the first call between the EMS and nurse. Staff J stated the EMS reported a five minute ETA (estimated time of arrival) of a person who fell while out mowing and had dizziness. At the end of the phone call, the Staff I reported to Staff J that Facility A was getting a patient. Staff J rehashed what Staff J had overheard, quick onset and couldn't use left side. Staff I called the EMS dispatch and obtained the cellular number of EMS Staff K. Staff I called the EMS and there was a discussion of whether or not Facility A was a stroke center. Staff J was shocked when questioned about the incident. Staff J reported he/she did not have any idea that Patient #21 and EMS were on Facility A's property. Staff I reported Patient #21 requested to come to Facility A. Staff J stated he/she was unable to hear the follow up call between Staff I and EMS Staff K. Staff J reported he/she would never turn a patient away from Facility A.

3. On 10/04/16 at 1:56 PM, Staff I, who worked in the emergency department at Facility A, was interviewed. Staff I reported he/she received a call from EMS Staff K regarding the EMS bringing Patient #21 to Facility A. Staff I took the report, hung up the telephone and told Staff J about why Patient #21 was coming in. Staff J instructed Staff I to call the ambulance back to have Patient #21 go to a Stroke Center. Staff I called the ambulance company and obtained the cell phone number for Non-Staff K who was with Patient #21. Staff I called the EMS and asked if they could take Patient #21 to the nearest Stroke Center. The EMS responded the EMS could and Patient #21 or family of Patient #21 had requested to be brought to Facility A. Staff I reported Staff J could hear the telephone call and stated we do not have a neurologist, can they go? The EMS Staff K reported they could go. Staff I reported EMS Staff K never stated "we are in your parking lot, at the back door". Staff I reported he/she did not ask EMS Staff K where the ambulance was.

4. Facility A's investigation report regarding a potential EMTALA violation was reviewed. The report stated an interview was conducted on 09/29/16 at 7:00 AM with Staff I and Staff J. The report stated Facility A received a call from the compliance officer of Facility B on 09/28/16 regarding a potential EMTALA violation. The compliance officer reported that according to an ambulance run report, Patient #21 was brought to Facility A's emergency department parking lot and the attendant was told by Staff I that Facility A was diverting Patient #21 to another facility. Staff I reported remembering the call coming in for Patient #21. Staff I reported the dispatcher relayed that Patient #21 was having stroke-like symptoms, provided Patient #21's vital signs and stated the estimated time of arrival was five minutes. Staff J was informed of the call and said to recommend transport to the closest Stroke Center. Staff I called the EMS Staff K back and informed the EMS medic of Staff J's recommendation. Staff I stated that at no time did the EMS Staff K state they had arrived and were in the parking lot. Staff I reported writing down the information on the Emergency Medical Services sheet but then destroyed it because Patient #21 never came to Facility A. Staff J reported he/she was sitting behind Staff I and could overhear the conversation. Based on the information that was given, which also included that Patient #21 could not use their left side, Staff J felt Patient #21 was having a large vessel stroke and recommended transfer to a Stroke Center, which Staff J felt was in the best interest of Patient #21 because there is literature that supports intervention over thrombolytics. Staff J insisted he/she did not tell EMS Staff K to "divert" and that at no time did EMS Staff K state they were in Facility A's parking lot. Staff J strongly stated that if Staff J had knowledge of Patient #21's arrival, Staff J would have attended to Patient #21.

5. The EMS run sheet for Patient #21 was reviewed. The sheet stated EMS Staff K was called to Patient #21's residence for disorientation and poor color. Upon arrival, Patient #21 was alert and oriented to person, place and time and breathing easy. Patient #21 reported having emesis times three since yesterday at 3:00 PM. Patient #21 complained of neck pain and a headache. Patient #21 reported Patient #21 had been presenting with disorientation intermittently since yesterday after cutting the grass with a hand mower. Patient #21 stumbled, hitting his/her right temporal region of the head. Patient #21 denied loss of consciousness. Patient #21 stated that he/she initially felt ok and gradually noticed weakness, headache and unsteady gait. Patient #21 denied any other complaints other than vertigo prior to the fall.

Upon assessment, left upper extremity weakness was noted and flaccidity was noted to the left lower extremity. No facial droop noted. Symmetry present with tongue midline. No visual disturbance or slurred speech. Patient #21 was placed on a cot and secured with straps. Patient #21 continued with emesis, coffee color in nature. Pulse oximetry was 92% on room air. Cardiac monitor revealed normal sinus rhythm. Zofran administered and emesis subsided, but Patient #21 continued to complain of nausea.

During transport, Patient #21 was continuously assessed and monitored. Left upper extremity paresis improved slightly as evidenced by stronger grip. Patient #21 was able to move left lower extremity and remained without further change and vitals were stable. The facility's emergency department was notified via mobile. Patient #21 complained of pain from 4-5 on a scale of 1-10 related to headache and neck pain, which radiated to the upper back region. Upon entry to Facility's A emergency department parking lot the medic received phone call from an emergency department nurse from Facility A at 8:18 AM, stating that the emergency department physician was diverting the EMS due to not being a stroke center. The Medic informed Patient #21 who requested Facility A's emergency department.

The Medic informed Facility A's emergency department of Patient #21's request, but Facility A's emergency department continued to divert the EMS. The Medic continued to monitor and reassess Patient #21, vital signs were taken at approximately 15 minutes while enroute to Facility B with no changes and Patient #21 was stable. Facility B's emergency department was notified via mobile. Patient #21 was placed in room 11. Verbal report provided to an emergency department registered nurse at Facility B and Patient #21's care was transferred.

6. The EMS run sheet Event Chronology was reviewed. The sheet documented the call was received on 09/25/16 at 7:26 AM. Dispatch time was 7:27 AM. Enroute time was 7:28 AM. At scene time was 7:35 AM. At patient time was 7:36 AM. Procedure performed at 7:43 AM. At destination time was 8:53 AM. In Service time was 9:15 AM.

7. The emergency department medical record of Patient #21 from Facility B was reviewed. The review revealed Patient #21 was admitted to the emergency department at Facility B on 09/25/16 at 9:37 AM and discharged on 09/30/16 at 1:30 PM. An Emergency Department Provider Note stated Patient #21 presented to the emergency department for dizziness, beginning yesterday. Patient #21 presents to the emergency department via EMS complaining of dizziness with associated headache, nausea and emesis. Patient #21 reported he/she was mowing the lawn, started getting dizzy, then fell against a clothes pole and hit the right side of the back of his/her head. Patient #21 stated he/she has not been feeling well since and complains of a headache that shoots into the neck, denies general weakness, shortness of breath, nausea/vomiting/diarrhea, chest pain, fever, chills, cough, or general cold related symptoms. The result of a computed tomography (CT) of the cervical spine revealed Patient #21 had a large right parieto-occipital intraparenchymal bleed with intraventricular component as described. No evidence for acute fracture or dislocation of cervical spine. The Emergency Department Provider Notes stated on arrival, Patient #21 presented with findings consistent with an intracranial hemorrhage. Stat CT confirmed this. Patient #21 was given Keppra. Neurosurgery was consulted. On reevaluation, Patient #21 continued to be awake, hemodynamics were stable. Patient #21 was admitted to the neuro intensive care unit (ICU). Patient #21 was given Zofran and Keppra. The disposition of Patient #21 stated Patient #21 was admitted to the critical care unit/intensive care unit and Patient #21's condition was serious.

The Hospital course stated Patient #21 presented secondary to dizziness and syncope. Patient #21 was taken to the emergency department where Patient #21 was found to have a large right parietal-occipital intracranial bleed. Patient #21 was admitted to the neurosurgical ICU and evaluated by neurosurgery. Follow up imaging with CT/MRI (magnetic resonance imaging) confirmed the bleed with no extension or worsening. No aneurysm or mass was noted. Patient #21 had a left sided hemiparesis due to the bleed as well as headache/neck pain. Patient #21 was treated conservatively and surgery was not felt necessary. Once pain/nausea was controlled and once cleared by neurosurgery, Patient #21 was cleared for discharge to acute rehab.