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Based on policy review, medical record review, central log review, Medical Staff Rules, diversion status report, staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings include:

Based on hospital policy and procedure review, medical record reviews, physician and staff interview, the hospital's DED (Dedicated Emergency Department) physician failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an emergency medical condition (EMC) existed for 1 of 21 reviewed patients who presented to the DED. (Patient #21).

~cross refer to 489.24 (a) & 489.24 (c), Medical Screening Exam - Tag C2406

Based on hospital policy review, Emergency Medical Treatment and Labor Act (EMTALA) central log review, Emergency Medical Services (EMS) run report and interviews, the hospital failed to maintain a central log on each individual who presented to the emergency department seeking medical care as to whether or not the patient refused treatment, or whether the patient was transferred, admitted and treated, stabilized and transferred or discharged for one of 21 sampled patients, (Patient #21).

Findings include:

Review of the hospital policy titled, "Emergency Department Record" effective date: 03/29/2021 revealed "Policy: An appropriate and complete Emergency Department record is maintained on each patient presenting for evaluation and treatment in the Emergency Department. ..."

Review of the hospital's central log for 08/22/2022 revealed Patient # 21 was not listed on the central EMTALA log. No medical record for Patient #21 was available for review at Hospital A.

Interview on 09/20/2022 at 1425 with the Chief Nursing Officer revealed Patient #21 was not listed on the central EMTALA log. Interview revealed Patient #21 remained in the EMS ambulance and was never brought into the ED at Hospital A.

Refer to C2406 for additional findings.

Based on policy review, medical record review, central log review, Medical Staff Rules, diversion status report, staff and physician interviews, the hospital's DED (Dedicated Emergency Department) physician failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an emergency medical condition (EMC) existed for one of 21 reviewed patients who presented to the DED, (Patient #21).

Findings include:

Review of the hospital policy titled "Medical Screening" effective 04/2021, revealed " ... 3. Medical Screening Examination: An evaluation sufficient to determine if an emergency medical condition or pregnancy with contractions exists. The exam includes appropriate resources routine available or accessible ... 4. Qualified Medical Personnel: For the purpose of this policy, a physician, a physician's assistant, nurse practitioner, a certified midwife, and/or obstetrical Registered Nurse is the person qualified to provide medical screening examinations to rule out an emergency medical condition. ... Policy: Name (Hospital A) provides a medical screening examination and ancillary service, within the capabilities of the Health System, to patients requesting examination or medical treatment. ... Procedural Guidelines: 1. Patients presenting to Name (Hospital A) requesting or having request made on their behalf for examination, have a medical screening examination performed by qualified medical personnel to determine if an emergency medical condition exists. ..."

Review of the hospital Medical Staff Rules and Regulations, last revised January 2019 revealed that a medical screening exam shall be performed by a qualified medical provider on all patients who present for emergency care or are in possible labor in conjunction with established hospital policy to determine whether an emergency medical condition exist or if the patient is in labor. Individuals qualified to perform a medical screening exam include: a physician, a physician's assistant, a nurse practitioner, a certified nurse midwife and an obstetrical registered nurse.

Review of the hospital policy titled "Triage Policy" effective date: 06/28/2020 revealed "Policy: Patients presenting to the Emergency Department are evaluated by a Registered Nurse to determine the nature of their presenting complaints, their condition, and their priority for receiving a medical screening exam, following the Emergency Severity Index triage algorithm. ..."

No medical record for Patient #21 available for review at Hospital A. Patient #21 presented to the Emergency Department via EMS.

Review of the EMS (ambulance) run report for Patient # 21 revealed a 34-year-old male who was transported to the facility's emergency department on 08/22/2022 at 2229 for a chief complaint of neck pain and chest pain. Review of the EMS run report revealed EMS was dispatched to Patient #21's residence for a chief complaint of "heart problems" on 08/22/2022 at 2132, arrived at the patient's residence at 2152, enroute to Hospital A at 2203 and arrived at Hospital A at 2229. Review of the EMS report revealed Patient #21 was ambulatory (assisted/walk) to the ambulance on the scene, placed in semi-fowlers position on the EMS stretcher and transported to Hospital A. Review of scene information on EMS report revealed " ... dispatched emergency traffic to the home residence of a 34 yr old male c/o (complaining of) sudden onset left side neck pain that turns into CP (chest pain) x(times) 30 mins. Upon arrival, EMS notes that pt is being escorted under an umbrella to truck by his father. Pt is able to board truck and sit upright on bench seat. EMS gets on back after applying PPE (personal protective equipment) to see that pt is COAx4 (conscious, oriented, alert to person, place, time and situation) with a GCS (Glasgow Coma Scale) of 15 (best results). EMS notes that pt appears anxious and jittery. Pt reports that he's having CP and states that 'my heart feels like its racing'. EMS has pt stand and sit with no assistance on stretcher and pt is secured via straps x3 and rails x2. Baseline vitals and 12 lead obtained. 12 lead reads Sinus Tachycardia with no ST elevation/depression noted. No imposters noted. Pt reports that he took 345 mg of ASA (Aspirin) PTA (prior to arrival). Pt asks EMS for O2 (oxygen). Pt placed on O2 via NC (nasal cannula) at 2 LPM (liters per minute). M11 (EMS truck number) enroute to Name (Hospital A). while enroute, pt c/o more neck pain that (sic) CP. Pt reports that he felt as if he was on the verge of an anxiety attack. This is when pt explains that he has been dealing with depression (sic) over the loss of his little daughter a year ago and has been struggling since. Pt admits to taking oxycodone and snorting some fentanyl approx. 1hr before incident. Pt transported without incident and with no significant changes to condition. Upon arrival at Name (Hospital A), EMS is told to wait on truck due to overcrowding. Pt is anxious and continues to tell EMS 'I need to be seen man, something is wrong' with vitals in normal limits except tachycardia. Name (Hospital A) cannot garauntee (sic) how long a wait will be, but that triage pts have been waiting for 4hrs. Pt reports that he wouldn't mind going to Name (Hospital B). EMS agrees to take pt to Name (Hospital B) as his condition has not gotten worse and pt is in no immediate danger. M11 enroute to Name (Hospital B). Pt is transported without incident and with no significant changes to condition. Upon arrival at Name (Hospital B), pt unloaded without incident. Pt taken inside for registration and assigned to RM#21. Pt able to slide self over to bed without assistance. Pt secured via rails x2. Pt care and report transferred to Name, RN. Further review of EMS run sheet revealed Pt #21 had medical history that included anxiety disorder, atrial fibrillation and substance abuse. Patient currently taking Metoprolol. Review of EMS documentation on the EMS run report revealed "Transportation Factors Affecting Care: Other: had to divert from Name (Hospital A) to Name (Hospital B) per pt request."

Review of the Diversion Report Status from December 6, 2021 through September 4, 2022 for Hospital A revealed no documented diversion status on 08/22/2022.

Interview on 09/20/2022 at 1415 with the Chief Nursing Officer revealed Patient #21 did not receive a medical screening exam in the Dedicated Emergency Department. Interview revealed the EMS staff left with Patient #21 prior to Hospital A getting a bed available.

Interview on 09/20/2022 at 1630 with RN #1 (Registered Nurse) revealed she was the charge nurse on 08/22/2022 from 7pm -7am. Interview revealed the charge nurse also had a room assignment after the 11am - 11pm nurse left sick at 2045. RN #1 stated she recalled someone informing her that a patient was coming in by EMS. Interview revealed reported on the radio the patient's vital signs, chief complaint of anxiety and sinus rhythm after completing a 12-lead Electrocardiogram (EKG) on the truck. RN #1 stated that when EMS arrived, she was preparing a patient for discharge, but had to give medications prior to discharge and get the room cleaned. While in the medication room, one of the EMS staff approached her and asked how long it would be before a room was available. RN #1 explained to EMS that she needed to give a discharged patient medication and would then discharge the patient, "so it shouldn't be long." Interview revealed the EMS staff said, "No problem" and walked back out of the ED to the ambulance. Interview revealed the second EMS staff (paramedic) came into the ED and asked the Provider "Do we know how long?" The Provider was unable to give an exact time but did inform EMS that the nursing staff were working on getting patients discharged. The Provider asked Paramedic "If she could give us a few minutes." RN #1 stated the EMS staff asked the Provider if it was going to be longer than 30 minutes. RN #1 stated she came out of the patient's room and overheard the EMS discusses wait time with the Provider. RN #1 stated she "informed the EMS staff that she could not give them an exact time but that she was working on getting discharged patient out of the ED now." Interview revealed the EMS staff told the Charge Nurse "Just going to take to Name (Hospital B). I'll take the heat for this."

Interview on 09/21/2022 at 0840 with RN #2 revealed he was working the 7p-7a shift on 08/22/2022. Interview revealed RN #2 answered the radio call in from EMS. EMS reported the patient's chief complaint was anxiety. RN #2 stated EMS did not mention anything about the patient using oxycodone and fentanyl. RN #2 stated the ED rooms were full and he asked EMS to hold the patient in the truck. Interview revealed the Charge Nurse was working on discharging a patient to ready a room for EMS. The Charge nurse was aware of the patient waiting in the EMS truck, however the Provider was not aware until the Paramedic came into the ED to inquire as to how long before a bed was available. Interview revealed RN #2 asked EMS to hold the patient in the truck based on COVID procedure instructions to keep EMS patients in the truck if there were no beds available in the ED. Interview revealed "I know now that it's not what we are supposed to do anymore."

Interview on 09/20/2022 at 1720 with Provider #3 revealed she was the Provider working in the ED on 08/22/2022 from 7p-7a. Interview revealed "It was an incredibly busy evening. We had probably 1-2 holds for admission, 3-4 transfer holds leaving only about a half of our 11 rooms available. Multiple patient waiting in the waiting room for 2 - 2 ½ hours." Interview revealed the Provider did not recall hearing the EMS radio call in or who answered the radio but have heard staff tell EMS in the past to "Please hold patient in the truck." Interview revealed the Charge nurse often asked the EMS to keep the patient in the ambulance for patient safety and monitoring. Interview revealed "Spoke with Paramedic who asked about bed and wait time. Explained that we had several holds in the ED and that we had a couple of discharges the nurses were working on to get a room available. Waiting on rooms on ED rooms to be cleared and cleaned." Interview revealed the Charge nurse came to the desk and explained to the Paramedic that they were holding patients for admission and transfers as well as multiple patient waiting in the waiting room. Charge nurse informed the Paramedic that she would get EMS a bed as soon as she could. Interview revealed the Paramedic told the Charge nurse that "If it's going to be too long, I'm going to Name (Hospital B." Provider stated the Charge nurse told the Paramedic "No we are not telling you to leave." Interview revealed that EMS was never told to divert to another hospital. Interview revealed at the time EMS arrived there was no capacity in the ED to place the patient anywhere. Interview revealed the Paramedic stated, "Patient getting anxious in back of truck." Interview revealed the Paramedic appeared "annoyed and wanted patient out of truck." Interview revealed the Provider was not aware of when EMS arrived at the hospital or how long the patient had been waiting in the truck. Interview revealed the Provider became aware of the patient waiting in the ambulance when the Paramedic came into the ED and spoke with the Provider to inquire about how long before a bed was available. Interview revealed the Provider did not complete a Medical Screening Exam on Patient #21 as the patient remained in the ambulance and she never saw the patient.

EMS Personnel were unavailable for interview.