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Based on facility document review and staff interviews, the facility staff failed to ensure an appropriate MSE (Medical Screening Exam) and necessary stabilizing treatment were provided to a patient that arrived on this facility's property via EMS (Emergency Medical Services) on 9/1/23 at approximately 1:30 a.m.

This facility electronically self-reported potential EMTALA violation to Virginia Department of Health (VDH) Office of Licensure and Certification (OLC) on 9/2/23 at 5:42 p.m. The surveyor conducted observations, interviews, document reviews and medical record reviews to determine compliance and found the facility has had no violations of EMTALA requirements for at least the past six (6) months and immediately in the evening of 9/1/23 reminded all staff via email that staff are not to redirect or divert anyone who comes on facility property. The facility Quality and Risk departments were tasked on 9/2/23 to develop EMTALA education for EMS partners and deployed new mandatory EMTALA module to all ED staff within 24 (twenty-four) hours. Two training modules titled Understanding and Complying with EMTALA were implemented, one for clinical staff and the other for non-clinical staff. At the time of the survey exit, the facility reported 77% (seventy-seven) staff completion of modules. All ED staff members are required to complete training by 9/22/23.

As directed by CMS (Centers for Medicare and Medicaid Services) the following Responsibilities of Medicare Participation Hospitals in Emergency Cases were reviewed: Assess/Monitor, Screening, Policies/Procedures, Treatment, Transfer/Discharge, Posting of Signs, and Central Log.


The facility was found in compliance, but previously out of compliance, with the EMTALA requirements at 42 CFR §489 (Rev. 7-19-19) regarding Responsibilities of Medicare Participating Hospitals in Emergency Cases.

Please refer to tag A-2406 for details.

Based on facility document review and staff interviews, the facility failed to ensure an MSE (medical screening exam) was completed for an individual presenting to the emergency department via EMS (emergency medial services) transport on 9/1/23 at approximately 1:30 a.m. and determine if an emergency medical condition existed for one (1) of twenty (20) emergency department (ED) patients included in the survey sample. Twenty records ED patient records were reviewed during the survey. The medical record for the above noted patient was not reviewed because the patient remained in the EMS vehicle and the registration process at this facility didn't occur.

The findings included:

This facility electronically self-reported potential EMTALA violation to Virginia Department of Health (VDH) Office of Licensure and Certification (OLC) on 9/2/23 at 5:42 p.m.

The surveyor conducted observations, interviews, document reviews and medical record reviews to determine compliance and found the facility has had no violations of EMTALA requirements for at least the past six (6) months and was at the time of survey in complaince, but previously out of compliance, with the EMTALA requirements at 42 CFR §489 (Rev. 7-19-19) regarding Responsibilities of Medicare Participating Hospitals in Emergency Cases.

During an interview on 9/18/23 at 12:15 p.m., Staff Members #2 (SM2) and Staff Member #4 (SM4) recalled the actions they had taken once they were alerted regarding the diversion of the patient. SM4 with the assistance of human resources sent an "all-hands" email on 9/1/23 to facility staff "clarifying we are not to redirect or divert anyone". SM2 and SM4 immediatelly started collaboration with Emergency Medical Services (EMS) partners to prevent recurrance and to develop EMTALA training for EMS staff . The facility's Risk Department had developed a new mandatory EMTALA training and deployed it within twenty-four (24) hours to all emergency department staff, to include house supervisors.

Staff Member #6 (SM6) recalled the events that occurred on 9/1/23 in an interview on 9/18/23 at 2:30 p.m. SM6 stated that they understood the doctor had requested during their call with EMS that they take the patient to another facility. When EMS arrived at this facility, SM6 was passing through the ambulance bay door and stated to EMS staff, "I thought you were going to (another facility)."

In an interview on 9/19/23 at 9:30 a.m., Staff Member #10 (SM10) stated that they requested in their conversation with EMS over the radio call that EMS take the patient to another facility SM10 stated, they were not aware EMS brought patient to this facility until couple days after the event occured.

The surveyor reviewed on 9/18/23 at 3:30 p.m., radio call recording EMS made to this facility on 9/1/23 at 1:30 a.m. and evidenced in part,
....(County EMS): "Calling to see if you want me to bring you this patient or go to (another hospital)?"
(SM #10): Is (patient) better now?
(County EMS): Yes.
(SM #10): You can take (patient) there, why not?
(County EMS): You're okay with there?
(SM #10) Yes.
(County EMS): Alright, thank you."

At the time of survey, the video surveillance was not available for surveyor's review.

The facility's EMTALA Violation SBAR (situation background, assessment and recommendation) dated September 6, 2023, was reviewed, and stated, in part, "S- Situation: EMS arrived to (this facility's) Emergency Department to transfer care of a pediatric patient. RN spoke with EMS in ambulance bay. EMS left the ED to transport patient to (another facility) without an MSE or appropriate transfer. B- Background: EMS requested permission to bring pediatric patient to our ED. The physician advised that the patient should go to (another facility)...A- Assessment: The ED RN and ED physician did not comply with EMTALA regulations. R- Recommendation: EMTALA is a law that requires all emergency departments to provide a medical screening exam to any individual that presents to the emergency department...Effective immediately, ED staff should not exit the ambulance bay doors to greet EMS staff. EMS will bring patients through the bay doors and the ED team will arrive the patient and treat accordingly...What to expect:...Mandatory education for all ED RNs, PARs, PCTs (patient care technician) and Physicians to be assigned ASAP (as soon as possible). All team members must review (this facility's) EMTALA policy. Meeting with all EMS agencies to discuss EMTALA and education. "

Two training modules were reviewed by the surveyor that were produced by Risk Management. Both were titled "Understanding and Complying with EMTALA". One was focused on clinical staff and the other focused on non-clinical staff. At the time of the survey entrance, the facility documented 75% (seventy-five) staff completed the training. By the survey exit, the facility reported 77% (seventy-seven) staff compliance with training. All ED staff members have until 9/22/23 to complete the training.

The surveyor reviewed the facility's policy titled ED-EMTALA Medical Screening Examination, Stabilization and Transfer, Effective Date: 01/01/2021 and Last Reviewed Date: 09/06/2023.