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

1. The facility failed to maintain an accurate and complete patient log. (Refer to A/C 2405)

2. The facility failed to ensure that two of seven patients' emergency transfer information were completed or included summary of the specific risks or benefits of transfer (Patients 6, and 20). (Refer to A/C 2409)

Based on interviews, and record review, the hospital failed to comply with the regulatory requirements for EMTALA when:

A patient that arrived at the ambulance bay (driveway) requesting assistance getting in to the Emergency Department was not placed on the Emergency Log and not provided a medical screening exam (MSE).

This deficient practice can impede the facility's ability to track the care provided to the patient who visits the ED seeking emergency medical care.

Findings:

During an interview on 12/12/24 at 10:27 a.m. with the Director of Accreditation and Regulatory (DAR), the DAR stated, the Patient "came to the ambulance bay, but decided not to stay when the clinical assistant (CA) went out to assist, I do not know the patient's name. They are not on the log".

During an interview on 12/12/24 at 2:30 p.m. with the Clinical Assistant (CA) the CA stated, "Security came to the tent for help, I exited the tent, spoke to the female driver, she said we are going to Hospital B and asked for directions".

During an interview on 12/13/24 at 9:29 a.m. with the Security Officer (SO), the SO stated "They [the patient] pulled into the ambulance bay, said he was a transplant patient and needed to get to the ED". Said he would get someone to help, went to the tent said someone outside is a transplant pt, can someone help me."

Review of the ED event timeline provided by security on 12/13/24 at 10:00 a.m. ED Event Timeline indicated the vehicle arrived on 12/2/24 at 00:59, the security officer encounter with vehicle was 49 seconds, SO then went to the tent for assistance, the SO returned with the ED staff, the ED staff encountered the vehicle at 1:01:54 a.m. The vehicle left the property at 1:02:28 a.m. 34 seconds later.

During an interview on 12/13/24 at 2:02 p.m. with the Director of the Emergency Department (DED), "Charge nurse was not aware of the patient".

Review of the Hospitals policy "The Emergency Medical Treatment and Active Labor Act {EMTALA), dated 1/2024, indicated, Purpose: To define and describe how Salinas Valley Health Medical Center (SVHMC) will comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) ... K. HOSPITAL PROPERTY means the entire main Hospital campus, including areas and structures that are located within 250 yards of the main buildings, ... Hospital property includes the parking lots, sidewalks, and driveways on the main Hospital campus.. A. SCOPE OF EMTALA: 1. EMTALA is applicable to any individual who "comes to the emergency department" seeking or needing an examination or treatment. C. CENTRAL LOG: Each dedicated emergency department of SVHMC will maintain a central log recording the names of individuals who come to the emergency department. The central logs will record the name of each person who presents for emergency services and whether the person refused treatment, was refused treatment by SVHMC or whether the individual was transferred, admitted, and treated, stabilized and transferred or discharged.

Based on interview, and record review the facility failed to obtain a completed transfer request on two of seven sampled transferred patient's (patient's 6, and 20) when:

1. Patient 6's transfer record lacked documentation of the receiving hospital's name, person accepting the transfer, the date and time of notification and the acknowledgment the patient was informed of the reason for transfer.

2. Patient 20's transfer record lacked documentation that indicated the medical condition had been stabilized or not stabilized, risks and benefits, receiving facility, person accepting, reason for transfer including dates and times and mode of transport.

These deficient practices placed the health of patients at risk.

Findings:

Review of Patient 6's ED notes, dated 9/27/24, indicated Patient 6 was brought to the Emergency Department for suicidal ideations (wanting to harm themselves) and using drugs. They were medically cleared, placed on a 5150 legal hold and transferred to an inpatient psychiatric facility.

Review of Patient 6's transfer documents, dated 9/27/24, had no indication that they were informed of the reasons for the transfer.

Review of Patient 20's Emergency Department notes, dated 12/11/24, indicated Patient 20 was brought to the Emergency Department (ED) for shortness of breath. Patient 20 was evaluated and treated, it was determined that Patient 20 needed to be transferred to a higher level of care for admission.

Review of Patient 20's Transfer documents, dated 12/11/24, had no indication of the patient's status, risks, and benefits, receiving facility, person accepting, reason for transfer including dates and times and mode of transport.
During an interview with Director of the Emergency Department (DED), on 12/13/24 at 2:15 p.m. the DED acknowledged, "all of the transfer documents were to be completed prior to the patient being transferred to another facility."