HospitalInspections.org

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Based on medical record (MR) review, document review, observation, and interview, the hospital failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA).

This failure potentially placed all patients arriving to the ED at increased risk of adverse outcomes.

Findings:

The hospital failed to provide Medical Screening Exams (MSE) within their capability and capacity to determine whether an Emergency Medical Condition exists, for one (1) of twenty-one (21) patients presenting to the Emergency Department (ED). Patient #1.

(See Tag A-2406)
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Based on medical record (MR) review, document review, interview, and review of Audio and Video recordings, in one (1) of twenty-one (21) MRs, the hospital failed to provide Patient #1 with an appropriate medical screening examination (MSE) within its capability and capacity. Specifically, no physical examination was conducted for Patient #1 who arrived by Ambulance to the entrance of the Emergency Department (ED), and after the Emergency Medical Service (EMS) crew were parked on the premises, they were redirected to another facility.

The failure to conduct a medical screening examination potentially placed Patient #1 at increased risk for adverse events, including an Emergency Medical Condition (EMC) potentially going unrecognized and/or untreated.

Findings:

Review of the Hospital Medical Staff Bylaws dated 03/28/2022, indicated that members of the Medical Staff shall abide by policies and procedures to ensure compliance with the Emergency Treatment and Active Labor Act (EMTALA).

Review of Hospital Policy titled, Emergency Medical Treatment and Labor Act (EMTALA) last reviewed 5/2021 documented that:
Every patient who comes to the Emergency Department for examination or treatment shall be given an appropriate medical screening examination to determine whether an emergency medical condition exists. Triage does not replace medical screening. The medical screening examination must be performed by a Physician, Nurse Practitioner (NP) or Physician Assistant (PA) ... When an individual is outside the dedicated Emergency Department, but on Hospital property within 250 yards of the main building, and requests examination or treatment for what may be an Emergency Medical condition, or has such request made on his or her behalf, or in the absence of a request based on the individual's appearance or behavior a reasonable layperson would conclude that the individual needs emergency examination or treatment EMTALA applies.

Review of the Ambulance Patient Care Report (PCR) dated 5/25/23 indicated:

Patient #1, a 48-year-old female called 911 for Emergency Medical Service (EMS) on 5/25/23 at 4:11 PM.
Ambulance vehicle #188 responded and arrived at Patient #1's home on 5/25/23 at 4:15 PM. The PCR documented, "Upon arrival patient was found lying down in bed accompanied by her boyfriend. Patient reports having abdominal and back pain and having done two stents the prior day (At Hospital B) on 5/24/23. The patient was escorted out of the house, assisted onto the stretcher, and loaded into the ambulance."

Patient requested to be taken to Hospital A which is the closest hospital (located South of her home).

EMS report documented retrospectively on 5/25/23 5:01 PM, "Near arrival at Hospital A, patient reported feeling pressure in her chest and pain radiating up to her face (cheeks). After updating the ED Twiage (a software communication application between the EMS crew and ED staff) with this new information the Med Control Doctor ( ED Physician working in Hospital A's ED) requested the EMS crew #188 needed to call and speak with him."

In the recorded telephone conversation with the doctor, EMS advised the ED doctor (Staff E) that they were on Hospital A grounds at that time and turning into the ED ambulance area."

The ED Doctor (Staff E) then noted, "Yes, but this hospital (hospital A) does not do stents, nor are the patients records on file and to reroute to another area hospital (hospital B) where the stents were previously placed. "

The PCR report documented, "At this time, EMS were already parked in the ambulance bay ...but the EMS ambulance crew then proceeded to reroute to Hospital B, and we notified Hospital B via Twiage of the diversion. "

The EMS crew documented on the PCR and noted at 5:01 PM, "while enroute to Hospital B from Hospital A the EMS crew encouraged and guided the patient to try to control her breathing. The Patient was transported into Hospital B's ED, and all care was transferred over to the care of that facility."
The Med Control Doctor from Hospital A was identified by EMS crew as Staff E (ED Doctor) in the EMS Patient Care Report.

As per the 'Twiage' (Text) Transcript dated 5/25/23 from 4:33 PM to 5:00 PM:
The transcript documented written communication text messages between the EMS crew and the Charge Nurse (Staff D) in Hospital A's ED.
Text messages as follows:
EMS: On 5/25/23 at 4:33 PM, "Patient #1 will be successfully delivered to Hospital A's ED."
EMS: 4:34 PM, "48 y/o with back pain, had two stents placed yesterday, ambulatory, and vital signs within normal limits."
Staff D (ED Charge Nurse): at 4:35 PM asked, "what kind of stents?"
EMS 4:37 PM: "Balloon, one in the iliac artery and the other in the right leg."
Staff D. 4:38 PM: "Okay".
EMS 4:46 PM: "Patient reporting chest pain, feels like pressure and also radiating up to her face."
Staff D 4:47 PM: "Where were the stents placed? What hospital?"
EMS 4:48 PM, responded, "Hospital B."
Staff D At 4:48 PM: "can you call the Med Control Phone (ED Phone Line)"

As per review of the Audio 'Twiage' Telephone Recording dated 5/25/23 between 4:48 to 4:49 PM:
Staff D (the ED Charge Nurse): " hold on the doctor is going to speak with you"
Staff E (ED Attending) "hello"
EMS, "we are turning into the hospital right now."
Staff E (ED Attending), "yes, but why are you bringing her here? She had her procedure at Hospital B, so why wouldn't you take her there?"
EMS: " she was requesting to come to Hospital A."
Staff E (ED Attending), "Yes, but she had her procedure at Hospital B ... all her records and all her blood work is there ...it doesn't make any sense to come here ...you know? She should go to Hospital B, where she just had a procedure done ...right?"
EMS: "ok ...ummm .... give me one second here ..."
The Call ended at 4:50 PM.

Review of Video surveillance obtained from Hospital A on 7/20/23 at 3:15 PM confirmed that Ambulance #188 was on the hospital grounds at the ED Ambulance Bay entrance between 4:50PM to 4:52 PM.
Video imaging confirmed the patient was within 250 yards of the ED at the same time the EMS workers were in communication with the ED Physician.

As per interview on 7/20/23 at 10:55 AM, Staff D (Charge Nurse Emergency Department) stated, the patient did not come into the ED. The Twiage text from EMS said she was a female patient who was status post a vascular stent procedure done at Hospital B ...she was having pain and shortness of breath. "I went over to Staff E and said to him come over to Twiage and look at the text messages. Then Staff E called the EMS line and spoke directly with the ambulance crew about how it would be more appropriate to take the patient to Hospital B. "I don't know what happened to the patient after that ...I didn't know where she was, and I don't know what the conclusion was..."

On 7/20/23 at 11:30 AM, Staff E (ED Attending) during interview reviewed the events that occurred on 5/25/23 regarding Patient #1. Staff E acknowledged that he was working in the ED and that Staff D explained to him that the patient had just had a vascular procedure done at Hospital B and was just released from there. Staff E explained that he called the EMS line directly and spoke with them on the line and explained to EMS that "the patient had her procedure at Hospital B, and wouldn't it be in her best interest to go there where they had all her records?" Staff E stated that the phone line connection was not clear. The call dropped. He did not know where the patient was when he was speaking with EMS, additionally he did not actually tell them not to bring the Patient to the ED and that he did not call Hospital B on that day regarding the patient.

As per interview with Staff F (Director of the EMS Ambulance) on 7/20/23 at 2:20 PM, Staff F confirmed that he was aware of the incident that occurred on 5/25/23 and that EMS Crew #188 had filed a report with him about the diversion that occurred from Hospital A and that the ED Doctor at Hospital A had advised the patient to be rerouted to Hospital B. Staff F stated the Ambulance crew was onsite when they were diverted, and the patient had chest pain and shortness of breath while in the ambulance. Staff F further stated that he had been working with Hospital B to provide them Transcripts and Audio Recordings of the event. Staff F reviewed the Global Tracking Position with Hospital B's EMS director and it clearly showed that the Ambulance (vehicle #188) that transported the patient was on the campus, at the door of Hospital A's ED when it left and then went to Hospital B.

During interview of Staff A (Director of Regulatory) on 07/21/2023 at 2:20 PM, Staff A confirmed that all ED Qualified Medical Providers should perform physical examinations on all patients entering the ED and acknowledged that the Ambulance with the patient was within 250 yards of the ED on 5/25/23 at or about 4:50 PM.