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Based on interview and record review, the facility failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) as evidenced by:

1. The facility failed to provide a medical screening exam (MSE) for Patients 1 and 2. (Refer to C 2406)

2. The facility failed to ensure the ED log included the names of all patients who presented for treatment. (Refer to C 2405)

Deficiencies were issued at C 2405 and C 2506.

Based on interview and record review, the hospital failed to maintain a central log in which each patient presenting for emergency care was listed along with all of the information required by CFR 489.24 and hospital policy. The Emergency Department (ED) log failed to include the name for one of 21 sampled patients (Patient 1).

This failure had the potential to result in the facility's inability to accurately track the care given to each patient.

Findings:

The facility's policy titled, "Transfer of Individuals, Emergency Rooms ," dated 11/30/20, was reviewed. It read, under Central Log: "1. Logs will be maintained on each person who comes seeking emergency care, including labor and delivery. Documentation on: a. Patient disposition (i.e. admitted, treated and discharged, treated and transferred). b. Patient refusal to further examination, treatment admission and/or transfer. c. The logs will be maintained for a minimum of ten years and according to policy. d. Per California State Law the following additional data will be kept in the central log: Means of arrival, age, sex, and medical record number."

On 12/22/20 at 1:23 pm, the California Department of Public Health (CDPH) received a fax from the Chief Nursing Officer (CNO) at this hospital (Hospital A). CNO reported that Patient 1 presented to their ED parking lot on 12/19/20, with stroke like symptoms. Registered Nurse (RN) 1 told the patient's family he would likely need to go to Hospital B (about 45 to 60 minutes away). Patient 1's family took him to Hospital B. CNO reported that no medical record was open for Patient 1 and he was not logged into the ED log book.

On 2/20/21, the ED log for 12/19/20, was reviewed and did not include the name of Patient 1 or other necessary information as required by regulation and facility policy.

During an interview on 2/8/21 at 4:45 pm, the Admitting Clerk (AC) said she was the admitting clerk who worked on 12/19/20 when Patient 1 presented to the ED. She said she was putting his information into the computer, but had not completed it, when RN 1 told her to delete Patient 1's chart. AC said she was new to this job and did as instructed by RN 1. AC said she later reported this to the Lead AC since it didn't seem right.

During an interview on 2/4/21 at 12:30 pm, RN 1 confirmed he told AC to delete Patient 1's name out of the computer. He said the ED Technician writes the names of the patients who come to the ED in the ED log and gets this information from the computer, but since Patient 1's name had been deleted from the computer, his name was not placed in the ED log.

Based on interview and record review, the facility (Hospital A) failed to provide an emergency medical screening (MSE) to determine if an Emergency Medical Condition (EMC) existed, for two of 21 sampled patients (Patient 1 and Patient 2).

1. Patient 1 presented to Hospital A's Emergency Department (ED) complaining of stroke like symptoms on 12/19/20 and did not receive a MSE. Patient 1 then went to Hospital B where he was admitted to the Intensive Care Unit (ICU) for a stroke. He was discharged home on 12/26/20.

This failure caused a delay in the assessment and treatment of a life threatening condition for Patient 1 and may have contributed to a decline in his overall health including permanent disabilities.

2. Patient 2 was confused and fell at home and an ambulance was called to provide care and transport to a hospital. Hospital A diverted the ambulance to another hospital although it was the closest facility, had available ED beds and ED staff and was not on diversion. The ambulance took Patient 2 to Hospital B where he was hospitalized for one week.

This failure caused a delay in the assessment and treatment for Patient 2 and had the potential to result in a decline in his overall condition.

Findings:

The facility's "Cobra and Emergency Medical Treatment and Active Labor Act (EMTALA) Guidelines, Emergency Department" policy, dated 11/30/20, was reviewed. It read: "All patients presenting to to the hospital for a non-scheduled visit and seeking care must be accepted and evaluated regardless of the patient's ability to pay. a. Hospital property is defined as: i. The physical area immediately adjacent to the hospital's main buildings; ii. Other areas and structures that are part of the hospital and are not strictly contiguous to the main building, but are located within 250 yards of the main building; and iii. Any other areas that are determined by the Centers for Medicare/Medi-cal Services (CMS) regional office on an individual basis to be part of the hospital campus. iv. Hospital property includes sidewalks, driveways and parking lots that are part of the main campus but does not include areas and structures within 250 yards of the main building that are not part of the hospital."
"b. Presenting to the emergency department is defined as: i. An individual who presents to a dedicated emergency department or presents on hospital property (other than a dedicated emergency department) and; 1. Requests examination or treatment for a medical condition; or 2. Has a request made on the individual's behalf for examination or treatment for a medical condition."
"2. All patients shall receive a MSE that includes providing all necessary testing and on-call services within the capability of the Hospital to determine whether an EMC exists. c. A medical record must be opened for every patient who presents to the hospital for emergency services even if the patient leaves before the MSE is performed. d. A MSE: i. Will be offered to any individual who comes to the ED. The MSE must be provided within the capability of the dedicated ED, including ancillary services routinely available to the dedicated ED. This MSE must be the same appropriate examination that the Hospital would perform on any individual with similar signs and symptoms, regardless of the individual's ability to pay."

1. On 12/22/20 at 7:58 am, the California Department of Public Health (CDPH) received a fax from Hospital B which indicated Patient 1 was brought to their ED, by private vehicle with stroke like symptoms, after having presented at Hospital A.

On 12/22/20 at 1:23 pm, the CDPH received a fax from the Chief Nursing Officer (CNO) from Hospital A. CNO reported that Patient 1 presented to their ED parking lot on 12/19/20, with stroke like symptoms. Registered Nurse (RN) 1 told the patient's family he would likely need to go to Hospital B (about 60 minutes away). Patient 1's family took him to Hospital B. CNO reported that no medical record was open for Patient 1.

A review of Patient 1's record from Hospital B, indicated he left the ED at Hospital A and arrived via private car, on 12/19/20 at 4:34 pm, complaining of right sided weakness, right facial droop, and aphasia (inability to speak) beginning at 1 pm. Labs and brain scans were completed and the ED physician diagnosed an intracranial hemorrhage (bleeding with the brain commonly caused by hypertension (high blood pressure) causing right sided paralysis, acute hypertensive emergency, and acute kidney injury. Intravenous (IV) medication was given to control Patient 1's hypertension and he was admitted to ICU. Patient 1 was discharged home on 12/26/20. The discharge summary indicated that Patient 1's communication and speech had continued to improve and most of his deficit was in his right arm and hand.

During an interview on 2/8/21 at 4:45 pm, the Admitting Clerk (AC) said she was the admitting clerk who worked on 12/19/20 when Patient 1 presented to the ED parking lot. She said a man entered the ED and told her he had Patient 1 in his car in the parking lot and thought Patient 1 had a stroke since he could not talk or move. She called RN 1 and told him there was someone in the parking lot who may have had a stroke and couldn't move. RN 1 said if he's had a stroke he'll need to go to Hospital B and said he was going out to the parking lot to check on the patient. RN 1 went out to the car but did not carry anything with him including no equipment to take a Blood Pressure (BP) and no wheelchair. RN 1 came back in about 10 minutes later and asked for Hospital B's address and said the family was going to take Patient 1 to Hospital B. AC said she looked up the address and gave it to RN 1 who went back outside. When RN 1 returned, she was still putting Patient 1's information into the computer and RN 1 told her to delete Patient 1's chart from the computer. AC said she was new to this job and did as instructed by RN 1. AC said she later reported this to the Lead AC since it didn't seem right.

During an interview on 2/4/21 at 12:30 pm, RN 1 said on 12/29/20, he got a call from AC that someone in a vehicle might be having a stroke so went to the car to do triage. He said there was a non-English speaking family with three family members and a male patient whose right side was flaccid and not able to answer questions. He talked to the family member whose English was the best and told her that they would do labs and a CT (computerized tomography, images taken inside the head)scan of the head and if the pt had a stroke he would have to go to Hospital B because they're the stroke hospital. The family member then asked, he needs to go to Hospital B? RN 1 said he'll need to go after we run tests. The family member then asked for Hospital B's address. RN 1 said he went inside the ED, got the address from AC and went out and gave it to the patient's family. The family said they would take him to Hospital B and drove off. RN 1 said when he came back inside the ED, he told AC the patient had left and told her to delete him out of the computer since he didn't come inside the ED.

RN 1 said he wanted to "lay eyes" on the patient and see how severe he was and that's why he went outside to the car. He confirmed he did not take a BP cuff with him to the car to check the patient's BP and did not take a wheelchair to the car. He said he would have brought the patient inside had he wanted to stay. RN 1 confirmed he did not go over the risks of the family driving the patient to Hospital B and agreed he could have done so when he gave them the address and could have asked the ED physician to come out and talk to the family. RN 1 again said he told the family they needed to do labs and scan to see if Patient 1 had a stroke and if he did they would have to try to get transportation arranged for the patient to go to Hospital B by ambulance.

During an interview on 2/11/21 at 1:20 pm, the CNO confirmed the 12/19/20 incident was an EMTALA violation. CNO said RN 1 should not have been telling the patient or family about what tests or scans were going to be done when that was beyond his scope of practice and a decision for the physician. If the RN was going out to lay eyes on patient in the parking lot he shouldn't have gone out empty handed. He should have been thinking, let's get the patient inside and should have prepared to do so immediately. CNO said the only time we would go out to the parking lot to screen was for possible positive Covid 19 (infectious respiratory flu type illness) patients so we could institute appropriate infection control protocols. She said RN 1 needed tools to get the patient's BP and questioned the intention of going out to the parking lot empty handed. CNO reported RN 1 also said he told the family, IF we can manage transportation, so that made it seem like we might have problems getting them out of here on transport and he did not try to convince them to stay. CNO said if a patient declines treatment or leaves against medical advice, the nurse must chart risks of refusal to get treatment. Patient 1's family brought him here for emergency treatment first instead of going to Hospital B and thought they would get care here but that didn't happen. CNO said the ED physician was inside the ED treating other patients and did not know what was going on until after this patient had already left.

During an interview on 2/11/21 at 1:55 pm, the ED Medical Director (EDMD) agreed the patient in the parking lot should have been brought inside to the ED and the RN should not have been discussing care with the patient since that is the physician's job.

2. The facility's "Triage, Emergency Room" policy, dated 11/30/20, indicated, In California, no ambulance can be redirected unless the hospital is on "diversion."

The facility's "Receiving Facility Agreement" dated 4/7/08, was made between Hospital A and the Northern California EMS (Emergency Medical Services). It indicated, "Generally, but without limiting the foregoing, HOSPITAL SHALL: 1. Be available to community with inbound ambulances and prepare appropriately to receive patients transported by ambulances."

On 1/29/21 at 3:32 pm, CDPH received a fax from the CNO at Hospital A. CNO reported that on 1/28/21, Patient 2 was being transported via ambulance. The ambulance indicated they intended to bring Patient 2 to the ED when they were diverted by RN 1 who suggested the ambulance turn and go towards Redding (about 45 minutes away), because he thought the patient sounded like he would need to be admitted and the hospital's inpatient unit was full. CNO reported their ED was not on diversion and they did not have a valid reason to divert the ambulance.

A review of Patient 2's record from Hospital B indicated Patient 2 arrived via ambulance on 1/28/21 at 4:57 pm. He had been found on the floor and had an altered level of consciousness. He was admitted to the medical unit with diagnoses that included hepatic encephalopathy (loss of brain function when a damaged liver doesn't remove toxins from the blood) and liver cirrhosis (damage) with ascites (fluid build up in the abdomen). He was discharged to Hospital A on comfort care on 2/4/21.

During an interview on 2/4/21 at 10:20 am, CNO said staff in the administration office overheard the ambulance call on the scanner on 1/28/21. Three staff members heard RN 1 told the ambulance to go to Redding. She confirmed the hospital did not own the ambulance. It was owned by the county where their hospital was located.

The ED log for 1/28/21 was reviewed with CNO on 2/4/21 at 10:20 am. She confirmed there was a total of 11 patients the whole 24 hour period. She said one patient had been discharged at 3:56 pm and another at 4:06 pm then there were no more patients in the ED until 4:39 pm. CNO said there were available ED beds and staff available at the time of this ambulance run, on 1/28/21 at around 4 pm. She also said there were no weather issues on that day. The ED physician on duty was not in the ED at the time of the ambulance call.

During an interview on 2/4/21 11:15 am, the paramedic (PM) said they picked up a patient who didn't meet trauma criteria and who regularly receives treatment at Hospital A. She said he was hypotensive (low blood pressure) and she decided the patient need to go to the closest hospital which was Hospital A. PM said she couldn't get an IV and he needed fluids for low BP. She gave report to a nurse at Hospital A who said if the patient needed to be admitted he would need to go to Redding. PM said she didn't think it was necessary to go to Redding and said that decision could be made after he was seen in the ED. PM said from that location they were 20 minutes to Hospital A and 45 minutes to Hospital B in Redding. RN 1 again told her to turn towards Redding and she did so. PM said she couldn't recall all the details about the report she gave the ER staff at Hospital but was pretty sure she told them she hadn't got an IV yet and definitely told the nurse that the patient was hypotensive because she told him the patient's BP. PM said Patient 2 was taken to Hospital B and she was told there that this patient was appropriate to be treated at Hospital A.

During an interview on 2/4/21 at 10:50 am, the Administrative Assistant (AA) said the scanner was located in the administration office so we could hear everything. On 1/28/21 in the afternoon the ambulance called the ED and gave patient's vital signs, age, oximeter (oxygen saturation). The ED RN said you need to transfer to Redding and PM said we will let you make that call once we get to the ED. The RN then told her to make a left turn and reroute to Redding. The ambulance paused then said, ok we'll reroute.

During an interview on 2/4/21 at 11 am, the Human Resources Generalist (HRG) overheard part of the conversation on scanner. One of the ED staff said the hospital was full and they (the ambulance) should go to Redding because there's more space there.

During an interview on 2/4/21 at 1:05 pm, the Medical Staff Coordinator (MSC) said she overheard ambulance on the scanner talking to the ED and the paramedic gave report for the patient. The ED RN said we have no beds for admissions and said they should take the patient to Redding. The paramedic told the RN we're going to bring the patient to ED and let him be evaluated but the RN said there were no beds in the hospital so the patient couldn't be admitted so our recommendation is for you to take the patient to Redding.

During an interview on 2/4/21 at 11:50 am, RN 1 said he was the RN in the ED on 1/28/21. He said he heard the ambulance radio go off and they were going to the home of a patient they were familiar with, as he comes to the hospital frequently. He and the ER physician talked while the ambulance was enroute to this patient's house. He said they had 10 inpatients with no empty beds and no ability to admit this patient and the majority of the time he needed to be admitted. The ER physician said dispatch needs to know we can't admit here. RN 1 said he called dispatch to let them know their medical unit in the hospital was full. The paramedic called and told him the patient's vital signs and said what do you want us to do and he told her they had no empty beds and it was recommended that they turn and head to Redding. He said he thought the BP was 95/40 or something like that and it's normal for this patient to be hypotensive. He said he couldn't recall if the paramedic mentioned an IV but knows the patient is a hard stick (it's difficult to get an IV). RN 1 confirmed they had open ED beds and they were not on diversion.

During an interview on 2/11/21 at 1:20 pm, CNO said she had discussed the policy with the ED physician and agreed it should reflect we should not divert unless we are on diversion status or the patient was a stroke, STEMI (heart attack), or trauma that was instructed to go to Hospital B. CNO said this patient was something we could have handled at our hospital.

During an interview on 2/11/21 at 1:55 pm, EDMD said he thought the ambulance diversion was an EMTALA violation and the ambulance should not have been diverted. He said this patient was sent back to them after his discharge from Hospital B. The ambulance should have come here as we had the capacity to keep the patient and stabilize him if we were unable to admit him here.