HospitalInspections.org

The hospital reported four dedicated emergency department(DED) locations with an average six month patient census of 9,257 a month. Based on document review, policy and procedure review and staff interviews the hospital failed to follow their policy and procedure to provide a medical screening exam(MSE) for one of one individual (Unknown #1) who presented on the hospital property via ambulance while the hospital was on diversion (an occurrence when the hospital lacks beds to admit new patients requiring in-patient services and patients coming to the emergency departments are diverted to another hospital that has beds available).
The hospital self-reported the Emergency Medical Treatment and Labor Act(EMTALA) violation to the Centers for Medicare and Medicaid Services(CMS) Region V11 on 1/30/2014. The hospital has had no EMTALA violations since at least 2003. A review of randomly selected emergency department records revealed no EMTALA concerns. A review of documents with corrective actions taken and planned by the hospital revealed appropriate education and policy revision to address the deficient practice.
Findings include:
- Policy titled "EMTALA-Definitions and General Requirements, Reference Number: LL.EM.001" reviewed on 2/6/14, directed staff to perform an MSE (medical screening examination) on any individual who comes to the emergency department, when an individual comes on hospital property and requests emergency medical care (other than the Dedicated Emergency Department (DED), or when a prudent layperson would recognize that an individual on hospital property requires emergency treatment or examination, though no request for treatment is made.
- The hospitals documentation reviewed on 2/6/14 at 9:00am of the "self reported (to the regional Centers of Medicare Services (CMS) possible EMTALA investigation " revealed on 1/12/14 area hospitals experienced high numbers of patients coming into the Emergency Department (ED) with flu like symptoms, pneumonia and other related illnesses causing many of the local hospitals to go on diversion status for adult critical care. On the afternoon of 1/13/14 as the hospital prepared to go on diversion status for all adult Intensive Care Unit(ICU) beds and the ED on the main campus because all ICU beds were full (except for one bed for a potential trauma patient). In house patients were being held in the catheterization lab, postoperative recovery areas, and the ED while waiting for ICU bed availability. The ED had five potential ICU patients in ED rooms. At 1:50pm the hospital notified One Call Center(the ambulance transfer center used to initiate transfers to or from the hospital) that the hospital was on diversion status.
During this time, the county's emergency medical service (EMS) had been called to transport a patient who was at an acute treatment center. The patient had requested to go to another area hospital (hospital #2) but EMS learned that hospital #2 was on diversion. The EMS driver began driving towards the hospital and radioed at 1:52pm saying they were en-route with the patient. The hospital informed EMS they were on diversion and should take the patient to the hospital of the patients preference. EMS stated they wanted to go to hospital #2 so the hospital instructed them to proceed to hospital #2.
The hospital investigation document revealed at approximately 1:55pm the house supervisor and the ED's Assistant Nurse Manager (ANM) were implementing diversion status and discussing resources when a female paramedic entered the ED and asked "can we still come here?" The ANM responded that they thought EMS were going to transport their patient to hospital #2. The house supervisor advised the paramedic that their hospital was on diversion. EMS then asked if they could go to the ED location and they responded "yes" and informed EMS that site C was not at capacity. The paramedic ran out the door and it was at this point the ANM realized that the patient may have been in the driveway with the paramedic, and even though they were on diversion status the patient must be seen in the ED, and provided an MSE.
Staff A, Registered Nurse (RN), house supervisor interviewed on 2/6/14 at 10:30am acknowledged they were on duty on 1/13/14 the day of the ED incident. Staff A said on 1/13/14 with the approval of the Chief Executive Officer the hospital went on diversional status because of lack of beds and high patient census. Staff A indicated on 1/13/14 they were unable to see the ambulance parking area when the paramedic came running in from the ambulance bay area. Staff A stated after the paramedic left the ED they went to ambulance bay area to see if the ambulance and patient were still on the hospital property since they realized the possible EMTALA violation and reported the incident to administration.
Administrative Nursing Staff B interviewed on 2/6/14 at 4:00pm reported the hospital recognized the potential Emergency Medical Treatment and Labor Act (EMTALA) violation, investigated the incident, self-reported the incident to the Centers for Medicare and Medicaid Services (CMS) and provided education to managers, directors, and staff in the hospital's ED, all staff involved in the incident, local Emergency Medical System (EMS), and One Call Service. Staff B provided the following corrective actions the hospital implemented and mandatory staff education outline to be completed by 3/31/14:
A.) The house supervisor was educated on the regulations to be followed when a patient arrives on hospital property seeking emergency treatment even if the facility is on diversion status, and the necessity of providing a medical screening examination (MSE).
B.) The Emergency Department (ED) Assistant Nurse Manager (ANM) was educated on the regulations to be followed when a patient arrives on hospital property seeking emergency treatment, even if the facility is on diversion status, and the necessity of providing a medical screening examination.
C.) All ED staff members and house supervisors at each of the hospital's ED campuses have been educated on the regulations to be followed when a patient arrives on hospital property seeking emergency treatment even if the facility is on diversion status, and necessity of providing a MSE. A formal EMTALA class had been assigned in Health Stream with a completion date by 3/31/14.
D.) To ensure a clear understanding of EMTALA obligations the hospital has incorporated this information into the Diversion Process Policy.
E.) The house supervisor orientation checklist was updated to include EMTALA obligations when the ED is on diversion status.
F.) The hospital's senior management, directors, and managers will be educated on the EMTALA requirements including providing a medical screening examination while on hospital property at leadership meetings on 2/6/14 and 2/16/14.
G.) The hospital EMS coordinator requested the EMS supervisor educate the EMS paramedics on all EMTALA regulations to be followed when a patient arrives on hospital property and the necessity of the hospital to provide a MSE.
Administrative Nursing Staff B interviewed and documents reviewed on 2/6/14 between 3:00pm to 5:25pm revealed the hospital provided education to the house supervisors, updated the house supervisors orientation checklist, provided EMTALA education to the ED registration staff, security staff, senior management/directors and managers power-point education, and revised the policy for emergency treatment while on diversion status.

The hospital reported four dedicated emergency department(DED) locations with an average six month patient census of 9,257 a month. Based on document review, policy and procedure review and staff interviews the hospital failed to follow their policy and procedure to provide a medical screening examination (MSE) for one of one individual (Unknown #1) who presented on the hospital property via ambulance while the hospital was on diversion (an occurrence when the hospital lacks beds to admit new patients requiring in-patient services and patients coming to the emergency departments are diverted to another hospital that has beds available).
The hospital self-reported the Emergency Medical Treatment and Labor Act (EMTALA) violation to the Centers for Medicare and Medicaid Services(CMS) Region V11 on 1/30/2014. The hospital has had no EMTALA violations since at least 2003. A review of randomly selected emergency department records revealed no EMTALA concerns. A review of documents with corrective actions taken and planned by the hospital revealed appropriate education and policy revision to address the deficient practice.
Findings include:
- Policy titled "EMTALA-Definitions and General Requirements, Reference Number: LL.EM.001" reviewed on 2/6/14, directed staff to perform an MSE (medical screening examination) on any individual who comes to the emergency department, when an individual comes on hospital property and requests emergency medical care (other than the Dedicated Emergency Department) (DED), or when a prudent layperson would recognize that an individual on hospital property requires emergency treatment or examination, though no request for treatment is made.
- The hospitals documentation reviewed on 2/6/14 at 9:00am of the "self reported (to the regional Centers of Medicare Services (CMS) possible EMTALA violation " revealed on 1/12/14 area hospitals experienced high numbers of patients coming into the Emergency Department (ED) with flu like symptoms, pneumonia and other related illnesses causing many of the local hospitals to go on diversion status for adult critical care. On the afternoon of 1/13/14 as the hospital prepared to go on diversion status for all adult Intensive Care Unit(ICU) beds and the ED on the main campus because all ICU beds were full (except for one bed for a potential trauma patient). In house patients were being held in the catheterization lab, postoperative recovery areas, and the ED while waiting for ICU bed availability. The ED had five potential ICU patients in ED rooms. At 1:50pm the hospital notified One Call Center(the ambulance transfer center used to initiate transfers to or from the hospital) that the hospital was on diversion status.
During this time, the county's emergency medical service (EMS) had been called to transport a patient who was at an acute treatment center. The patient had requested to go to another area hospital (hospital #2) but EMS learned that hospital #2 was on diversion. The EMS driver began driving towards the hospital and radioed at 1:52pm saying they were en-route with the patient. The hospital informed EMS they were on diversion and should take the patient to the hospital of the patients preference. EMS stated they wanted to go to hospital #2 so the hospital instructed them to proceed to hospital #2.
The hospital investigation document revealed at approximately 1:55pm the house supervisor and the ED's Assistant Nurse Manager (ANM) were implementing diversion status and discussing resources when a female paramedic entered the ED and asked "can we still come here?" The ANM responded that they thought EMS were going to transport their patient to hospital #2. The house supervisor advised the paramedic that their hospital was on diversion. EMS then asked if they could go to the ED location and they responded "yes" and informed EMS that site C was not at capacity. The paramedic ran out the door and it was at this point the ANM realized that the patient may have been in the driveway with the paramedic, and even though they were on diversion status the patient must be seen in the ED, and provided an MSE.
Staff A, Registered Nurse (RN), house supervisor interviewed on 2/6/14 at 10:30am acknowledged they were on duty on 1/13/14 the day of the ED incident. Staff A said on 1/13/14 with the approval of the Chief Executive Officer the hospital went on diversional status because of lack of beds and high patient census. Staff A indicated on 1/13/14 they were unable to see the ambulance parking area when the paramedic came running in from the ambulance bay area. Staff A stated after the paramedic left the ED they went to ambulance bay area to see if the ambulance and patient were still on the hospital property since they realized the possible EMTALA violation and reported the incident to administration.
Administrative Nursing Staff B interviewed on 2/6/14 at 4:00pm reported the hospital recognized the potential Emergency Medical Treatment and Labor Act (EMTALA) violation, investigated the incident, self-reported the incident to the Centers for Medicare and Medicaid Services (CMS) and provided education to managers, directors, and staff in the hospital's ED, all staff involved in the incident, local Emergency Medical System (EMS), and One Call Service. Staff B provided the following corrective actions the hospital implemented and mandatory staff education outline to be completed by 3/31/14:
A.) The house supervisor was educated on the regulations to be followed when a patient arrives on hospital property seeking emergency treatment even if the facility is on diversion status, and the necessity of providing a medical screening examination (MSE).
B.) The Emergency Department (ED) Assistant Nurse Manager (ANM) was educated on the regulations to be followed when a patient arrives on hospital property seeking emergency treatment, even if the facility is on diversion status, and the necessity of providing a medical screening examination.
C.) All ED staff members and house supervisors at each of the hospital's ED campuses have been educated on the regulations to be followed when a patient arrives on hospital property seeking emergency treatment even if the facility is on diversion status, and necessity of providing a MSE. A formal EMTALA class had been assigned in Health Stream with a completion date by 3/31/14.
D.) To ensure a clear understanding of EMTALA obligations the hospital has incorporated this information into the Diversion Process Policy.
E.) The house supervisor orientation checklist was updated to include EMTALA obligations when the ED is on diversion status.
F.) The hospital's senior management, directors, and managers will be educated on the EMTALA requirements including providing a medical screening examination while on hospital property at leadership meetings on 2/6/14 and 2/16/14.
G.) The hospital EMS coordinator requested the EMS supervisor educate the EMS paramedics on all EMTALA regulations to be followed when a patient arrives on hospital property and the necessity of the hospital to provide a MSE.
Administrative Nursing Staff B interviewed and documents reviewed on 2/6/14 between 3:00pm to 5:25pm revealed the hospital provided education to the house supervisors, updated the house supervisors orientation checklist, provided EMTALA education to the ED registration staff, security staff, senior management/directors and managers power-point education, and revised the policy for emergency treatment while on diversion status.