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Based on interview and record review, the hospital (Hospital 1) failed to maintain an accurate emergency department (ED) central log when ED staff failed to record on the central log one of 20 sampled patients, Patient 100, who arrived to the Hospital 1 ED by ambulance and was then diverted to Hospital 2. This failure resulted in an inaccurate ED central log, and potentially prevented Hospital 1 from tracking the care of other patients who presented to the ED seeking care for emergencies.

Finding:

Review of Hospital 1's document "Emergency Department Radio Log" indicated that on 4/23/23 at 1:33 a.m., ambulance number 681 called with an estimated time of arrival of five minutes with a 71 year-old female with AMS (Altered Mental Status). Under column "Final ER Diagnosis" was written "Diverted to [Hospital 2] (per [Hospital 2] request)."

Review of Patient 100's medical records from Hospital 2 revealed she was seen in the ED at Hospital 2 on 4/23/23. Patient 100's ED Provider Note, dated 4/23/23, indicated, "EMS (emergency medical services) states that the pt (patient) is coming from [skilled nursing facility named] for positive blood cultures. Pt was taken to [Hospital 1] ED, per EMS the ED doctor at [Hospital 1] ED told EMS to take pt here."

Review of Hospital 1's ED central log for 4/23/23 revealed Patient 100 was not documented on the log when she arrived.

During an interview on 10/3/23 at 11:39 a.m., ED Technician (Tech) A stated that when patients came to the ED by ambulance, her main role was to make sure the patients were registered. ED Tech A stated that, unless it was a stroke or a heart attack, she would wait until the ambulance crew brought the patient into the ED and then she would get the patient's name and date of birth. ED Tech A stated she recalled the situation on 4/23/23 and verified she took the call from the ambulance crew documented on the radio log at 1:33 a.m. ED Tech A stated she recalled that when the ambulance rolled up to the ambulance bay, Physician B went out to the EMS crew, and then they (EMS) took the patient to Hospital 2. ED Tech A stated the patient did not come inside the ED.

During an interview and concurrent record review on 10/4/23 at 11:58 a.m., Quality Manager confirmed Patient 100 was not documented on the ED central log on 4/23/23, when she arrived via ambulance to Hospital 1's ambulance bay.

During a telephone interview on 10/4/23 at 3 p.m., when queried, Nurse D stated the reason why Patient 100 did not make it on the central log was Patient 100 was not registered as a patient at the ED. Nurse D stated every patient was supposed to go on the log if they came to the ED as a patient.

During an interview on 10/5/23 at 9:50 a.m., Nursing Director stated if Patient 100 was not registered then she would not be on the log. Nursing Director verified Patient 100 should have been put on the log when she arrived via ambulance to Hospital 1's ambulance bay.

Review of hospital policy and procedure "EMTALA Transfer Policy," last revised 9/2023, indicated under "Definitions" section, "Emergency Medical Care Log: Is a record maintained of all individuals who come to a department seeking emergecy care. The purpose of the log is to track the care provided to each individual who comes to [Hospital 1] seeking emergecy medical care." The policy and procedure revealed no further mention of the log.

A policy and procedure for recording patients presenting for care at the ED on the central log was requested but not provided.

Based on interview and record review, the hospital (Hospital 1) failed to: 1. Provide a medical screening exam (MSE) for one of 21 sampled patients, Patient 100. This failure resulted in a delay in care when Patient 100's ambulance arrived but was diverted from Hospital 1 to Hospital 2, twenty miles away; 2. Specifically indicate in the medical staff bylaws and rules and regulations who is qualified to perform a MSE in the emergency department (ED). This failure resulted in bylaws and rules and regulations that are unclear on who can perform MSEs in the ED.

Findings:

1. Review of Patient 100's Hospital 2 blood culture (laboratory test to check for bacteria or other germs in a blood sample) results note, dated 4/22/23 at 9:41 p.m., indicated a pharmacist discussed the results with a physician "who wants pt (patient) to return for labwork and possibly IV abx (intravenous (directly in the vein) antibiotics). Called [skilled nursing facility and staff member named] for pt to return for further labwork."

Patient 100's ambulance "Prehospital Care Report" indicated the ambulance was responding to a 911 call received on 4/23/23 at 12:18 a.m. The report indicated the ambulance left the skilled nursing facility (SNF) where Patient 100 resided at 1:18 a.m. The ambulance crew narrative note indicated, "Medic 681 dispatched for elevated lab values. . . . Staff (at SNF) were unable to reasonably state reasoning for transport destination and only stated that its [sic] because her labs were elevated. . . . Base contact was made and stated that they wanted the patient to go to [Hospital 2] so EMS (emergency medical services) diverted for [Hospital 1] to [Hospital 2]. The patient was monitored for changes during transport. Patient report was given to the RN at the receiving facility." Patient 100's blood pressures were recorded by the ambulance crew as follows:

1:08 a.m. 98/48
1:09 a.m. 102/56
1:26 a.m. 82/47
1:33 a.m. 55/39
1:41 a.m. 77/48
1:46 a.m. 116/72
2:03 a.m. 108/65
2:08 a.m. 114/66

Patient 100's ambulance "Prehospital Care Report" further indicated that at 1:26 a.m., 1:29 a.m., and 1:32 a.m., one of the crewmembers attempted unsuccessfully to place an IV in Patient 100's left arm and right hand.

Hospital 1's document "Emergency Department Radio Log" (log of ambulance crews' calls to the ED approximately five to ten minutes prior to arrival to inform hospital staff they are enroute with a patient) indicated that on 4/23/23 at 1:33 a.m., ambulance number 681 called with an estimated time of arrival of five minutes with a 71 year-old female with AMS (Altered Mental Status). Under column "Final ER Diagnosis" was written "Diverted to [Hospital 2] (per [Hospital 2] request)."

Review of Patient 100's medical records from Hospital 2 revealed she was seen in the ED at Hospital 2 on 4/23/23. Patient 100's ED Provider Note, dated 4/23/23, indicated Patient 100 was 71 years old and had a medical history of schizophrenia (mental illness characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities) and hypertension (high blood pressure), among others. Patient 100's ED Provider Note further indicated, "EMS states that the pt is coming from [skilled nursing facility named] for positive blood cultures. Pt was taken to [Hospital 1] ED, per EMS the ED doctor at [Hospital 1] ED told EMS to take pt here."

Patient 100's Hospital 2 Hospitalist History and Physical note, dated 4/23/23, indicated Patient 100 was "brought here after going to [Hospital 1] where they had said they should bring her here for continued antibiotic treatment. It was very strange that she is here now and under our care. She has positive blood cultures . . . . She cannot give a history but she can somewhat interact. She appears dehydrated and toxic." The hospitalist further documented that Patient 100 was being admitted to the hospital for sepsis (a life-threatening medical emergency in which an infection triggers a chain reaction throughout the body).

During an interview on 10/3/23 at 11:39 a.m., ED Technician (Tech) A stated she recalled the situation on 4/23/23 and verified she took the call from the ambulance crew documented on the radio log at 1:33 a.m. ED Tech A stated she remembered that a patient from a SNF was picked up by EMS, but nobody at the SNF had told the ambulance crew that she needed to be taken to Hospital 2. ED Tech A stated Physician B called Hospital 2 and Physician B was told, as far as she knows, that they were waiting for Patient 100 at Hospital 2. ED Tech A stated she was sitting next to Physician B when he was on the phone with Hospital 2. ED Tech A stated the ambulance rolled up to the ambulance bay, Physician B went out to the ambulance crew, and then they (EMS) took Patient 100 to Hospital 2. ED Tech A stated Patient 100 did not come inside the ED.

During a telephone interview on 10/3/23 at 3 p.m., Physician B stated he recalled Patient 100 and the situation on 4/23/23. Physician B stated Patient 100 had just been discharged from Hospital 2 a day or two before (4/21/23 or 4/22/23). Physician B stated Hospital 2 had called Patient 100's SNF and asked the staff to send Patient 100 back to Hospital 2 because her blood cultures had come back positive. Physician B stated the medic told him things were "a little chaotic" at the SNF while they were picking up Patient 100 and they ended up at Hospital 1 instead of Hospital 2. Physician B stated that since the Hospital 1 electronic health record did not connect with the Hospital 2 health record for him to know anything about the patient, and since Patient 100 was stable, he decided that it was best to send Patient 100 to Hospital 2 for continuity of care. Physician B stated he did not think it was necessary to do her work-up all over again and there was nothing to stabilize.

During the same telephone interview on 10/3/23 at 3 p.m., Physician B stated the ambulance backed into the ambulance bay and the medic gave him report on Patient 100, but the medic did not indicate why they brought the patient there to Hospital 1. Physician B stated Patient 100 stayed in the ambulance and he could see that she was "not toxic appearing," but he did not "listen to her heart and lungs or anything," and he did not speak to her. Physician B stated either the medic or the nurse told him Patient 100's vital signs (measure of the basic functions of the body, including body temperature, blood pressure, pulse and respiratory (breathing)). Physician B stated he did a MSE but he did not document it. When asked if the Hospital 1 ED had the capability to care for Patient 100, Physician B stated that they did, unless she needed a specialist, in which case she would need to be transferred.

During an interview on 10/4/23 at 9:02 a.m., ED Medical Director stated he recalled discussing Patient 100 and the situation on 4/23/23 with Physician B a few months ago. ED Medical Director stated Hospital 1 had the capability to care for a patient with potential sepsis. ED Medical Director stated the potential was there of Patient 100's condition being an emergency. When asked about Physician B's medical screening exam of Patient 100, ED Medical Director stated he did not know if a MSE was done because Physician B did not document anything. ED Medical Director stated, "A medical screening is documented in my world." When queried, ED Medical Director stated Patient 100 should have been put on the ED central log (registered) and she should have been medically screened. ED Medical Director stated Physician B could have gotten Patient 100's information from Hospital 2 for continuity of care. ED Medical Director stated if Patient 100 needed to be sent to Hospital 2, the formal transfer process should have been started. ED Medical Director stated, "We don't ever turn anyone away or divert ambulances."

During a telephone interview on 10/4/23 at 2:30 p.m., Physician C stated she recalled Patient 100 coming to the Hospital 2 ED on 4/23/23. Physician C stated that her HPI (History of Present Illness) note in Patient 100's chart was what the EMS crew told her verbatim. Physician C stated she recalled thinking that it was atypical for a patient coming by ambulance to stop at another hospital first before coming (to the Hospital 2 ED). Physician C verified Patient 100 had a history of hypertension. When informed of Patient 100's blood pressures documented by the ambulance crew, Physician C stated Patient 100 was septic and her blood pressures were "a little low."

During a telephone interview on 10/4/23 at 3 p.m., Nurse D was asked about Patient 100 presenting to the ED via ambulance on 4/23/23. Nurse D stated she recalled the incident and stated she was working that night. When asked if ED Tech A had taken the EMS call announcing Patient 100's imminent arrival to the ED, Nurse D stated, "I think she did." Nurse D stated neither she nor the other nurse working in the ED that night had taken the EMS call. Nurse D stated she was in the area and heard some of the EMS call and she assumed Patient 100 needed a sepsis workup, but did not recall why, exactly. Nurse D stated after EMS called the facility, Physician B placed a call to the SNF, but she was not sure why. Nurse D stated during the SNF conversation, she understood Patient 100 needed antibiotics because her (current) antibiotics were not working. When asked if Physician B called Hospital 2, Nurse D stated, "yes" and stated she believed she heard it (the conversation); she stated she thought there was a plan in place for Patient 100 (at Hospital 2).

During the same telephone interview on 10/4/23 at 3 p.m., when asked if she made contact with Patient 100, Nurse D stated she had, "no hands-on" (touching) with Patient 100 and did not speak with her. When asked why Patient 100 was not documented on the ED central log, Nurse D stated the decision to send her to Hospital 2 was probably the reason she was not registered as an ED patient (electronic registration process to put the patient on the log). When asked if Patient 100 should have been put on the central log, Nurse D stated every patient was supposed to be put on the log, but "diversion happened" so it did not take place.

During an interview on 10/5/23 at 9:50 a.m. with Nursing Director and Chief Medical Officer (CMO), Nursing Director stated the only circumstance in which it was acceptable to divert an ambulance would be if the CT (computer tomography, imaging study of internal organs) scanner was down and the ambulance was bringing a stroke patient. Both Nursing Director and CMO verified that Patient 100's blood culture results from Hospital 2 could have been obtained in order to provide the treatment she needed. Nursing Director stated any patient who arrived to the ED should be brought into the ED and seen (by ED staff). CMO clarified that any patient who arrived to the ED should be brought into the ED, triaged (preliminary assessment of patients in order to determine the urgency of their need for treatment), and evaluated for a potential emergency condition. When informed of Patient 100's blood pressures documented by the ambulance crew, Nursing Director stated that as a nurse the first thing she would think of was sepsis and "it is our responsibility to look at that." CMO stated he would think the ambulance crew would start IV fluids for blood pressures as low as Patient 100's.

Review of hospital policy and procedure "Patient Triage and Assessment," last revised 9/2023, indicated, "All patients presenting for treatment in the Emergency Department will be triaged in a timely manner by a registered nurse or physician, and be treated in order of medical priority. Patients will be pulled to an ED room immediately after quick registration is completed . . . ."

Review of hospital policy and procedure "EMTALA Transfer Policy," last revised 9/2023, indicated, "Any person who presents to [hospital named] dedicated Emergency Department requesting assistance for a potential emergency medical condition/emergency services will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists." The section titled "Definitions" revealed, "Medical Screening Examination (MSE): Is the process required to reach, with reasonable clinical confidence, whether or not an emergency medical condition exists or a woman is in labor. This is documented in the electronic health record (EHR)."

2. During an interview and concurrent review of Hospital 1's Bylaws and Rules and Regulations on 10/5/2023 at 10:44 a.m., Area Quality Specialist was queried about the documents not specifying what provider types (physicians, nurse practitioner, etc.) were authorized to perform MSE's in the ED. Area Quality Specialist stated the documents "implied" who performed MSE's. When CMO was asked if it was acceptable for the Bylaws and Rules and Regulations to imply, rather than specify, what providers were authorized by Hospital 1 to perform MSE's, he stated he would reach out to Hospital 1's consultants and obtain recommendations regarding Bylaw language addressing MSE's.