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Based on document review, policy review, medical record review, and interview the hospital failed to ensure an appropriate and complete medical screening exam (MSE) was performed for 1 of 21 (Patient #1) patients seeking medical treatment for an emergency medical condition.

The findings included:

Patient #1 was a 14-year-old female who presented to Hospital #2's Emergency Department (ED) after being treated on 9/30/2024 at an out-of-state hospital ED. On 9/30/2024, Patient #1 was transferred from Hospital #1 (out-of-state hospital) to Hospital #4 (in-state hospital located in Town #3), via ground ambulance for critically low hemoglobin (a protein in red blood cells that carries oxygen from the lungs to the body's tissues and organs), critically low hematocrit (the percentage by volume of red cells in the blood), hypotension (low blood pressure; a condition in which the force of the blood pushing against the artery walls is too low) and tachycardia (a heart rate of more than 100 beats per minute at rest). En route to Hospital #4 Emergency Medical Services (EMS) became concerned with increased hypotension, nausea and vomiting, and syncope (fainting or a sudden temporary loss of consciousness). Based on the decomposition of vital signs, EMS contacted the receiving hospital's (Hospital #4) physician who instructed EMS to seek care for Patient #1 at the nearest emergency room for a blood transfusion and to avoid hemorrhagic shock (a form of shock caused by insufficient blood volume in the body; can be caused by dehydration or blood loss). EMS transported Patient #1 to Hospital #2's (Hospital #2 was located in Town #2) Freestanding Emergency Department (located in Town #1), the closest ED. Upon arrival to Hospital #2's Freestanding ED, ED Physician #1 questioned EMS as to who authorized them to bring Patient #1 to a Freestanding ED. ED Physician #1 told EMS there was no blood available at Hospital #2's Freestanding ED and instructed EMS not to remove Patient #1 from the stretcher and continue to Hospital #4. There was no triage assessment or MSE conducted on 9/30/2024 for Patient #1 at Hospital #2's Freestanding ED.

Refer to 2406.

Based on document review, policy review, medical record review, and interview the hospital failed to ensure an appropriate and complete medical screening exam (MSE) was performed for 1 of 21 (Patient #1) patients seeking medical treatment for an emergency medical condition.

The findings included:

1. Review of the Hospital's "Medical Staff Rules and Regulations" last revised 09/2024, revealed, "Preamble- The Medical Staff shall initiate and adopt such Rules and Regulations as it may deem necessary for the proper conduct of its work and shall periodically review and revise its Rules and Regulations with current Medical Staff practice...VI. EMERGENCY SERVICES/MEDICAL SCREENING...1. Emergency Services A. Members of the Medical Staff shall accept responsibility for Emergency Service care in accordance with the Medical Staff Bylaws, Emergency Department policies and procedures and applicable state at federal law...2. Medical Screening Exam [MSE]...Federal and State laws and regulations provide that any individual who comes to Hospital property or premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by individuals qualified to perform such examination to determine whether or not an emergency medical condition [EMC] exists. An appropriate MSE includes routinely available ancillary services An MSE shall be provided to determine whether an emergency medical condition exists..."

2. Review of the hospital policy "TN [TENNESSEE] EMTALA [Emergency Medical Treatment and Active Labor Act] Medical Screening Examinations and Stabilization" last revised 09/2024 revealed, "...PURPOSE: To establish guidelines for providing appropriate medical screening examinations (MSE) and any necessary stabilizing treatment for an appropriate transfer...Policy: An EMTALA obligation is triggered when the individual comes to a dedicated emergency department (DED) and 1. the individual or representative acting on the individual's behalf requests and examination or treatment of a medical condition... Procedure: When an MSE is required- A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC exists: to any individual...who requests such an examination...An MSE shall be provided to determine whether or not the individual is experiencing an EMC [emergency medical condition]...An MSE is required when...The individual comes to a DED of a hospital and a request is made by the individual or on the individual's behalf for examination and treatment for a medical condition...Extent of the MSE: a. Determine if an EMC exists. The hospital must perform and MSE to determine if an EMC exists...b. Definition of an MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital. C. An on-going process. The individual shall be continuously monitored...until it is determined whether or not the individual has an EMC...1. Depending on the individual's presenting symptoms, an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also includes performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT [computed tomography] scans, and other diagnostic tests and procedures...No Delay in Medical Screening or Examination...EMS. A hospital has an obligation to see the individual once the individual presents to the DED whether by EMS or otherwise. A hospital that delays the MSE or stabilizing treatment of any individual who arrives via transfer from another facility, by not allowing EMS to leave the individual, could be in violation of EMTALA...the hospital must assess the individual's condition upon arrival of the EMS service to ensure the individual is appropriately prioritized based on his or her presenting symptoms to be seen for completion of the MSE..."

3. Medical record review revealed a 14-year-old female who presented via private vehicle to Hospital #1's Emergency Department (ED) (out-of state hospital) on 9/30/2024 at 3:09 PM with complaints of heavy vaginal bleeding. The triage nursing assessment was initiated at 3:13 PM and revealed the chief complaint "Started period on Friday and having heavy bleeding and lots of clots started yesterday and fainted was washing hands and everything started going dark and passed out today, was here yesterday."

The MSE was initiated at 3:24 PM and revealed Patient #1 presented with vaginal bleeding, reported heavy menstrual bleeding with clots for the past 3 days, with 2 near syncope (light headedness/near fainting) over the past 2 days. The ED Physician documented Patient #1 had been seen in Hospital #1's ED on 9/29/2024 and had a hemoglobin of 10.2 (the normal average hemoglobin level for a 14-year-old female is 13.5 grams/deciliter) with mild orthostasis (orthostasis/orthostatic hypotension is a condition where blood pressure drops when moving from a seated position to a standing position). Patient #1 was treated with Iron on 9/29/2024 and discharged home. Patient #1 reported another syncopal episode prior to arrival in ED on 9/30/2024. The MSE physical exam revealed Patient #1 had an elevated heart rate of 103 and low blood pressure of 100/68. Laboratory results revealed low red blood cell count- 2.46, (normal red blood count for a 14-year-old female is 3.8-5.0 million cells per microliter of blood) critically low hemoglobin (Hgb)- 6.7 (hemoglobin is a protein inside red blood cells that carries oxygen from the lungs to tissues and organs in the body and carries carbon dioxide back to the lungs) and critically low hematocrit- 20.0 (A hematocrit test measures the ratio of red blood cells to the total volume of blood in your body. Normal range for adolescent female is 30-44. Anemia is a condition where your body doesn't have enough healthy red blood cells or hemoglobin to carry oxygen to your body's tissues). The ED Physician documented "Medical decision making: Worsening Orthostasis noted today, unable to stand from sitting, Hb [Hgb] significantly lower than yesterday. 4:00 PM- spoke with [named physician] about patient [#1] and will admit for transfusion and further work up, Labs type and cross ordered [A type and crossmatch is a blood test that determines a patient's blood type and Rh factor, and matches the patient's blood with a donor's blood to prepare for a transfusion] 4:30 PM Repeat CBC shows Hb 6.7...message sent to [named physician] and feels better served at higher level of care with GYN [gynecological services]. Patient's mom prefers [named Hospital #4] due to family in [Town #3]. Patient #1 was administered 1000 milliliters hydration bolus [a single dose with a large amount of fluid given as quickly as possible] Intravenous at 3:40 PM. A physician at Hospital #4 [located in Town #3] accepted Patient #1. Patient #1 was transferred from Hospital #1 to Hospital #4 for specialized pediatric care via ground ambulance on 9/30/2024 at 5:55 PM..."

4. Review of the Emergency Medical Services (EMS) trip report dated 9/30/2024 revealed Patient #1's primary diagnosis was vaginal hemorrhage. The EMS unit arrived at Hospital #1 on 9/30/2024 at 5:46 PM to transport Patient #1 to a higher level of care at Hospital #4. The EMS narrative revealed, "...PT [patient] is a 14 year old female who came to the [named Hospital #1] on Friday [9/27/2024- 3 days prior to this visit]...for heavy bleeding and clots during their menstruation. PT Hgb was noted to be 10.2 on Friday. PT came to [Hospital #1] today due to continuous bleeding...[Hospital #1] reported...Hgb is now 6.7. Pt is borderline hypotensive [low blood pressure] and tachycardic [abnormally elevated heart rate above 100 beats per minute]...EMS inquires as to blood administration and Hospital #1 reports they do not have the availability of blood products..." EMS documented Patient #1 reported no pain, was non-hypoxic (low oxygenation level of a patient's body) and tachycardic EMS departed Hospital #1 with Patient #1, en route to Hospital #4 on 9/30/2024 at 6:02 PM.

The following vital signs were documented by EMS:
6:09 PM: BP - 131/56, Pulse-120;
6:20 PM: BP - 106/50, Pulse-117;
6:34 PM: BP - 72/40, Pulse-117;
6:37 PM:BP - 62/34, Pulse-106;
6:48 PM: BP - 96/47, Pulse 107;
6:58 PM: BP - 72/32, Pulse 108;
7:08 PM: BP - 82/62, Pulse 116;
7:20 PM: BP - 78/52, Pulse 115; and
7:29 PM: BP - 78/52, Pulse 114.

The EMS narrative further revealed, "...During transport EMS monitors for any trending negatives or acute status changes...PT noted approximately 30 minutes into transport to have inadequate MAP [mean arterial pressure-arterial pressure is the force of blood against the walls of the arteries and a vital measurement that ensures enough blood reaches the body's organs and tissues] PT reports feeling dizzy and nauseated. EMS obtains PIV [peripheral intravenous line is a tiny, short, flexible tube, called a catheter] access to the right cephalic vein [a superficial vein in the arm]...for cannulation [the placement of the catheter into the vein] due to the expectation of transfusion [blood transfusion a common treatment for anemia]...EMS notes line to flush freely [a small amount of saline in a syringe is pushed through the catheter flows with difficulty] with brisk blood return ...line is saline locked [a leur-lock device in which saline is put through into the vein to keep the vein open in case the patient requires intravenous fluids] and secured...Pt vomits before EMS is able to confirm allergen status and rights to administer Zofran [anti-nausea medication]. EMS administers Zofran with good effect noted...EMS confirms hypotension with manual auscultation [manual check of BP] and upgrades to emergency traffic [lights and sirens]. EMS initiates a small BOLUS of LR [Lactated Ringer's injection is used to replace water and electrolyte loss in patients with low blood volume or low blood pressure] in attempt to allot for permissive hypotension without further dilution of Hgb. Pt reports their vision to be blurred and 'black around the edges' as well as feeling extremely dizzy as if they may pass out. EMS contacts medical control [dispatch system] at Hospital #4 and speaks to [named accepting physician with Hospital #4] and informs doctor of current situation, EMS informs doctor approximately 49 min [minutes] ETA [estimated time of arrival]. EMS further informs they currently only have the option to potentially give TXA [tranexamic acid, a drug used to control bleeding] which PT does not meet protocol, or initiate Norepinephrine infusion to increase NIBP [noninvasive blood pressure] for adequate MAP. [named accepting physician with Hospital #4] informs EMS to do neither option and divert to nearest emergency room so PT can receive blood transfusion until they are stable enough for transport to Hospital #4, so as to avoid PT arresting [heart stop beating] due to hemorrhagic shock [a life-threatening condition that occurs when the body loses too much blood and can't meet the body's need for oxygen and nutrients]...EMS diverts to the nearest emergency room [ER] which at the time was [named Hospital #2's freestanding ED in Town #1]. EMS calls via cellphone and gives report to RN [Registered Nurse] along with an estimated ETA. Upon arrival EMS is directed into room #3 and PT is taken by stretcher into room. EMS begins giving report to RN when [named ED Physician #1] enters the room and demands EMS not unbuckle the PT or transfer the PT to the ER bed. [named ED Physician #1] states 'Who authorized you to come here? This is not an appropriate facility, this is a standalone clinic, not an emergency room.' [named ED Physician #1] informs EMS they do not have blood products, do not have a laboratory that can perform [perform] a type and screen and cannot get the PT the help they need. EMS is informed by RN in the room that [named Hospital #3 located in Town #2] would be able to best care for this PT. [named ED Physician #1] again asked EMS 'Who told you to come here?...You should not have come here.' EMS informs MD that they are not from this state and were not aware their Emergency Room was not an actual Emergency Room and incapable of emergency care. EMS transports PT back to ambulance and then continues emergency traffic to Hospital #3. EMS contacts charge nurse @ [at] facility and gives full report as well as estimated ETA...EMS continually monitors PT during transport for any trending negatives or acute changes of which EMS notes hypotension and tachycardia. EMS does attempt to mitigate hemorrhagic shock with ambient temperature increase with good effect..." Patient #1's care was transitioned to the ED staff at Hospital #3 on 9/30/2024 at 7:40 PM.

5. Review of the late entry nursing triage from Hospital #2's Freestanding ED, dated 10/4/2024 (4 days after Patient #1 presented seeking care for vaginal bleeding and decompensated vitals) revealed Patient #1 presented to Hospital #2's Freestanding ED on 9/30/2024 at 7:19 PM. RN #1 documented, "Per EMS Crew Pt presents with C/C [chief complaint] of vaginal bleeding. BP enroute was 66/44 and heart rate 120. Enroute to [named Hospital #4]. Was advised to go to nearest hospital by medical control ...Pt in sitting position on stretcher. Awake. Alert. Color WNL [within normal limits]. No obvious sweating noted. No grimacing/guarded or restlessness." RN #1 documented Patient #1 was discharged at 7:21 PM, 2 minutes after she arrived seeking care. RN #1 documented a Patient note on 10/4/2024 at 1:38 PM, "[named ED Physician #1 communicated to EMS Pt [#1] stable for continuing transport to [named Hospital #4]."

Review of a late entry for the MSE from Hospital #2's Freestanding ED, dated 10/4/2024 (4 days after Patient #1 presented seeking care for vaginal bleeding and decompensated vitals) revealed ED Physician #1 documented vaginal bleeding as the chief complaint. The free text history and Present illness notes of the MSE revealed, "I partially overheard the radio call with EMS on the line stating they were en route to the ED...with a pt who was hypotensive and bleeding out. The nurse did mention to me that the paramedics indicated that the pt was having profuse vaginal bleeding and still noted with low blood pressure. At this point my main focus was on how to resuscitate this pt when she presents to the ED. I was unaware there was whole blood in the ED to initiate an immediate blood transfusion since we have to contact the blood bank at [named Hospital #2] for blood including type and crossmatch. I finally decided we will at least continue with fluid resuscitation when pt arrives. When EMS arrived, they went into room #3 with the pt. I went into the room to see the pt. The Paramedic came forward to me and stated they had just bolused the pt with about 900 mls [milliliters] of saline en route and did not have sufficient time to check the BP before their arrival...He then stated the BP is now 119/82. [There was no documented evidence from EMS medical record to support Patient #1's BP was ever recorded at 119/82] At this time, I did glance at the pt who was calmly laying on the stretcher without visible acute distress. Pt was alert and halfway sitting up at the stretcher without any exhibition of distress or discomfort. I then mentioned to the nurses that the transfer of this pt to [named Hospital #4] should continue. The Paramedic then mentioned if they had rechecked the BP after the 900 mls fluid bolus before their arrival at the ED [Hospital #2 Freestanding ED] that they would have continued to transport the pt to Hospital #4 without having to stop at [named Hospital #2 Freestanding ED]. The medical screening was not completed at this point before they left the ED..." ED Physician #1's late entry documented Patient #1 was discharged home in stable condition with a Primary Diagnosis of Vaginal Bleeding.

Patient #1 was not discharged home, nor transported to Hospital #4, but was instead transported to the next closest Hospital ED [Hospital #3] for medical care and treatment due to her continued unstable vital signs and potentially life threatening medical condition.

6. Review of the ED record from Hospital #3 revealed Patient #1 was triaged at 7:48 PM with chief complaint patient was being transported via EMS to Hospital #4 for decreased hemoglobin and blood pressures, related to heavy menses with clots. The triage vital signs were BP-133/87 and Pulse-112. The triage nurse documented the heart rate was abnormal but the patient was alert and oriented and moving all extremities. The MSE was initiated at 7:51 PM and revealed a 14-year-old female with complaints of vaginal bleeding with symptoms beginning a week ago, with associated symptoms of syncope. The ED Physician documentation revealed, "At their worst the symptoms were severe, in the emergency department they have improved. Patient was seen at outside facilities in [out-of-state] and noted to have falling hemoglobin. She developed tachycardia and hypotension en route to [named Hospital #4]. The paramedics were instructed to divert to a facility which could provide blood for her...She is awake and alert with clear sensorium, she has not diaphoretic...Hemoglobin is 6.9. We had trauma blood ready on arrival, but I believe that the patient's condition did not necessitate emergent transfusion of crossmatch blood. Therefore, we will give her a unit of blood and I have contacted [Hospital #4] and she will be transported expeditiously ..." Patient #1 had a urinalysis, Complete Blood Count and cardiac monitoring at Hospital #3. Patient #1 was educated and consented to receive blood products. Patient #1 was administered one (1) unit of packed red blood cells at 9:20 PM which was infusing upon transfer to Hospital #4 at 9:45 PM. Patient #1's BP was 112/64 and Pulse 108 at 9:42 PM, just prior to transfer.

7. Review of the ED record from Hospital #4 revealed Patient #1 arrived via EMS on 9/30/2024 at 10:21 PM. The Nursing triage note at 10:28 PM revealed, "Arrives as a transfer via EMS. Per report, pt began with vaginal bleeding beginning 2 days ago. Pt found to have Hgb of 6.9. Blood transfusion initiated and ongoing...Breaths even, unlabored. Skin appropriate and warm. Blood infusing upon pt arrival...[named accepting Physician for Hospital #4] at bedside.

The MSE was initiated at 10:45 PM and revealed Patient #1 was a transfer from another hospital for heavy menstrual bleeding and symptomatic anemia. The physical examination by the ED Physician revealed Patient #1 appeared pale had a pulse of 103. Laboratory results revealed Patient #1's Hemoglobin was 7.3. The ED Course and Medical Decision making narrative revealed, " ...presents with heavy menstrual bleeding. On exam patient has active ongoing vaginal bleeding and she is tachycardic to the 100s. Suspect ongoing symptomatic anemia due to ongoing bleed. Unclear etiology of bleed at this time given no family history of bleeding disorders and patient has not had heavy menstrual bleeding in the past and denies sexual activity. Had negative pregnancy test at outside hospital today. Discussed patient's case with gynecology who recommended obtaining pelvic ultrasound and starting on progesterone and estrogen pills every 4 hours for cessation of bleeding. They will continue to reassess the patient throughout her hospital stay. CBC [complete blood count- measures the number and types of cells in the blood], CMP [comprehensive metabolic panel - measures 14 substances in your blood to provide an overall picture of your body's chemical balance and metabolism], coags [to measure blood clotting] ordered. Hemoglobin 7.3 on CBC. Patient consented for blood and 1 more unit packed red blood cells was ordered. Pelvic ultrasound currently pending. Discussed patient's case with hematology who had no further recommendations, will admit for further care. Plan of care discussed with mother, aunt, patient at bedside. Patient at time of admission appears floor appropriate despite ongoing bleeding with blood pressure 110/71, heart rate 103..."

Review of a Gynecological consult note dated 10/1/2024 at 12:45 AM revealed, "...presented as ER [emergency room] to ER transfer for heavy vaginal bleeding Gynecology consulted for further management recommendations...She reports her most recent period started on 9/27, it was normal until yesterday when the bleeding increased and she started saturating a pad/hour. She presented to her local ED [Hospital #1] where she was found to have Hgb 10. She was discharged home on PO [by mouth] iron, however continued to have heavy bleeding...She had two episodes of syncope today and re-presented to her local ED. Her Hgb was found to be 6.9 and the decision was made to transfer [named Hospital #4]. En route she became hypotensive to 50's/30's...the ambulance stopped at another OSH [outside hospital] where they started, her on 1 U [unit] pRBC [packed red blood cells] for the remainder of her transport to [named Hospital #4]. On arrival...tachycardia-110, normotensive...Labs notable for WBC [white blood cells] 7.6, H/H [Hgb and Hematocrit] 7.3/23...She has never experienced bleeding like this before. She endorses dizziness and lightheadedness...Physical Exam...Heart: Mildly tachycardic...Abdomen: Soft, non-tender, non-distended, no masses or organomegaly [abnormal enlargement of organ] Pelvis: Tanner Stage 4 development [The Tanner staging scale, also known as the sexual maturity rating, is a tool used by healthcare providers to track physical changes during puberty] pad 100% saturated, normal external genitalia without lesions, introitus [external opening of the vaginal canal] normal and well estrogenized with slow trickle of dark vaginal bleeding, no other abnormal discharge... Assessment and Plan...Recommend transfusion with 1U pRBC [packed red blood cells] and repeat CBC..."

Patient #1 was admitted inpatient to Hospital #4 on 10/1/2024 at 2:11 AM for further evaluation and treatment.

8. In an interview on 10/21/2024 at 1:23 PM, the Vice President of Operations for Hospital #2 verified there was no MSE or nursing assessment documented for Patient #1 on 9/30/2024. The VP of Operations stated the late entries, dated 10/4/2024 (4 days after Patient #1 presented via EMS for care) were a part of the corrective action plan implemented after the incident was identified.

In an interview on 10/22/2024 at 10:48 AM, the Laboratory (Lab) Supervisor at Hospital #2's Freestanding ED stated the Freestanding ED had 2 units of O negative blood stored in the lab. The Lab Supervisor stated if the units were used, staff would call the main campus and ask for 2 more units to be delivered within the same day. On 10/22/2024 at 10:50 AM, the surveyor observed 2 units of blood in a refrigerator in the lab.

In an interview on 10/22/2024 at 12:20 PM, Licensed Practical Nurse (LPN) #1 from Hospital #2's Freestanding ED verified she took a call from an EMS unit on 9/30/2024. LPN #1 confirmed the call was related to Patient #1, a 14-year-old with vaginal bleeding who had a decompensation of vital signs during transport from an out-of-state hospital to Hospital #4. The LPN stated EMS reported they called Hospital #4 who directed them to take Patient #1 to the nearest hospital. LPN #1 stated when she took the call she provided the information to RN #1 and ED Physician #1. LPN #1 stated when EMS rolled Patient #1 into the ED, Physician #1 instructed EMS not to take the patient off the stretcher. LPN #1 stated she then went on break and had no other knowledge of the incident.

In an interview on 10/22/2024 at 12:34 PM, the ED Nursing Manager from Hospital #2's Freestanding ED verified on 9/30/2024, there were 2 units of blood in the lab. The ED Nursing Manager stated the nurse and physician should have created a medical record for Patient #1 when she presented via EMS. The ED Nursing Manager stated RN #1 was attempting to get information on Patient #1 and she barely got a name before the ED Physician instructed EMS to continue on to Hospital #4 for the higher level of care.

In a telephone interview on 10/22/2024 at 3:29 PM, RN #1 from Hospital #2's Freestanding ED verified she was working on 9/30/2024 when Patient #1 arrived via EMS for vaginal bleeding and hypotension. RN #1 stated EMS called ahead and stated the patient had become unstable and Hospital #4 (receiving hospital) instructed them to seek care at the closest Emergency room. RN #1 stated when Patient #1 arrived via EMS she went to retrieve a scale and brought it to room 3, where EMS was directed to take Patient #1. RN #1 stated when she returned with the scale she heard ED Physician #1 say "Don't take the patient off the stretcher, why did you come here?" RN #1 stated ED Physician #1 told EMS this was a Freestanding ED and they were delaying Patient #1's care. RN #1 stated Patient #1 was alert and awake in a sitting position on the stretcher. The surveyor asked if she had ever witnessed anything similar while working in the ED. RN #1 stated, "No I haven't." RN #1 verified the ED had blood stored in the lab. RN #1 stated she had to look at the Patient's arm band as EMS was wheeling her out of the ED to get her name.

In a telephone interview on 10/23/2024 at 9:47 AM, the ED Medical Director from Hospital #2's Freestanding ED stated he was familiar with the case for Patient #1 who presented to Hospital #2's Freestanding ED on 9/30/2024, via EMS. When asked what the expectation was for Patient #1's care, he stated the patient would be taken into the ED for an assessment and either they [staff] could allow EMS to leave, or they could ask EMS to stay and possible transport the patient on to a higher level of care after the assessment/ medical screening exam. The surveyor asked the ED Medical Director if an MSE was provided to Patient #1. He stated there was no medical screening exam documented, he further stated ED Physician #1 took Patient #1's BP but did not document. The ED Medical Director verified there were 2 units of blood at Hospital #2's Freestanding ED. The Medical Director stated that prior to last year, the ED did not have any blood products, but when Patient #1 presented on 9/30/2024, there was blood available. The ED Medical Director stated ED Physician #1 reported to him when Patient #1 presented she was awake alert and in no distress and he did not want to delay her care.

In a telephone interview on 10/28/2024 at 8:19 AM, ED Physician #1 from Hospital #2's Freestanding ED verified he was working in the ED when Patient #1 presented via EMS on 9/30/2024. ED Physician #1 stated he heard the EMS call come in on 9/30/2024 that Patient #1 was bleeding out and had a low blood pressure. ED Physician #1 stated he was not aware the ED had 2 units of blood in the lab and when he heard the call he panicked. ED Physician #1 stated, "I feel really badly for some of my mistakes... I tried to get EMS to go somewhere with blood..." ED Physician stated Patient #1 was lying on the stretcher in upright position and she was not in distress. ED Physician #1 stated EMS reported the last blood pressure taken, as 119/82 and EMS reported if they had checked the blood pressure before pulling into Hospital #2, they would have continued on to Hospital #4. ED Physician #1 stated, "I should have done a full blown MSE at that time, but I did not..." When asked if on-call physicians were available for Obstetrics and Gynecology, he stated, "Yes, available at [named Hospital #2's main campus located in Town #4] and to us at [Town #1]..."