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Based on review of the hospital's Central Log, interviews, review of the hospital's video footage, review of the hospital's Medical Staff Bylaws and Medical Staff Rules and Regulations, Hospital A failed to provide an appropriate Medical Screening Examination (MSE) for 1 of 1 patient who presented via Emergency Medical Transport with a chief complaint of gastrointestinal bleeding when she presented to Hospital A's Emergency Department (ED) on 10/31/2022 and did not receive a Medical Screening Examination. (Patient #1)

The findings include:

Refer to A2406.

Based on review of the hospital's Emergency Department (ED) central log, interview, and review of the hospital's EMTALA (Emergency Medical Treatment And Labor Act) policies and procedure, the hospital failed to ensure that all patients presenting to the Emergency Department requesting assistance was placed on the hospital's central log and the following information was recorded: whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for 1 of 1 patient who presented to Hospital A's Emergency Department with gastrointestinal bleeding. (Patient #24)

The findings include:

Review of Hospital A's video footage on 11/17/22 at 1:50 PM revealed Patient #24 arrived at Hospital A at 23:48:42 via stretcher vomiting blood upon entrance with Emergency Medical Services (EMS) Transport Crew #1. Video observations revealed Patient #24 arrived at the nurse station via EMS Transport #1 with paperwork in hand. At 23:49:18, three staff members are seen at the nurse station with two patients on stretchers in front of the station. At 23:49:25, one of the staff members from behind the desk went to the end of the nurse station by EMS transport # 1 and has a conversation with EMS staff. The Registered Nurse left exits down the hallway and returned at 23:50:06 with Registered Nurse (RN) #1. RN #1 has a conversation with EMS Transport #1 crew and at 23:50:30, RN #1 turned around, walked away, and sat down behind the nurse station. At 23:50:35, an unidentified physician walked past the patient and EMS Transport Crew #1 and entered an office. At 23:50:43, one of the EMS Transport Crew #1 medic made a hand gesture as if they were leaving and exited from the nurse station at Hospital A with Patient #24 via stretcher at 23:50:56 which was 2:14 (two minutes and fourteen seconds) post entrance.

Review of the Dedicated Emergency Department (DED) central log on 11/14/22 at 1:10 PM revealed the central log entries for 10/31/2022 showed no documentation for Patient #24 who presented to the ED via ambulance transport seeking treatment for gastrointestinal bleeding on 10/31/2022 at approximately 11:30 PM. The ED failed to create a patient chart or have documentation of a transfer or discharge.

During an interview on 11/16/22 at 7:19 PM, Registered Nurse (RN) #1 verified that he/she was on duty on 10/31/2022 at 11:30 PM when a patient arrived via ambulance transport with hematemsis. RN #1 stated, "During a flu surge, we had people in the hallways, and we were holding a lot of patients and other hospitals were without beds. The pager went off from the call center, and the patient that was coming was vomiting blood. We had a lot of patients we were already holding for GI (Gastrointestinal) beds greater than twenty-four hours waiting for transfer. I went to the ED (Emergency Department) doctor and told him/her the patient information given. The ER (Emergency Room) physician was okay with us sending the patient to another hospital. I and the physician tried to contact EMS (Emergency Medical Services)Transport Crew #1 prior to their arrival. I contacted the AOD (Administrator On Duty) as well. While I was waiting, the person at dispatch answered finally and said they would contact the truck. A room in the ED was prepared prior to the patient's arrival though. The physician waited but they(EMS) took too long and he/she had to leave from by the telephone waiting with me. They (EMS Transport #1) arrived and entered the double doors. I met them at the nurse station. I gave them(EMS) Room 6 for EMS to put the patient in. The EMS Transport #1 crew did not give me the transfer sheet or anything. She/He (EMS Transport #1 staff) went back to the patient and his crew person. They conversated and decided they would go to Hospital B's ED(Receiving hospital). The patient stated that his/her family would be looking for him/her here, and EMS said they would call the family to see if it would be okay. The doctor here never saw the patient. We don't know his/her name, age, nothing. The only info (information) we have is what was paged over to us. I had no conversation at all with the EMS crew on the side about the patient. I told them I called their dispatch to try to get them(dispatch) to divert, but since they were here, they(EMS) could go to Room #6. Then he (EMS Transport #1) went back and conversated with his partner and the patient. Less than three minutes was the entire event. I informed the AOD after they left. She(AOD) knew that I was contacting their dispatch and was okay with it. We were also on "Out of County" diversion and only EMS Transport #2 is to come to the ED. Even if it was EMS Transport #2, I would have still tried to get them(EMS) to divert. I felt it was in the best interest for the patient. About thirty minutes later, I saw the AOD in passing and she/he(AOD) told me to write it up. I called my manager and she/he(Manager) asked what happened. She/he(Manager) said she/he would talk with her boss and they would take it from there. They told me they would self-report the incident, and they were going to give us more EMTALA training. They sent out a flyer in an email and you scanned the flyer so they would know who did it and who didn't. It was an interactive training".

Hospital policy, entitled, "Hospital A Emergency Medical Treatment and Labor Act-EMTALA", revealed, "7. Requirement to maintain a Central Log:
7.1 Each Hospital A Health facility that provides ED and/or OB Screening will maintain a Central Log(s) in accordance with EMTALA.
7.2 The Central Log(s) on each individual that "comes to the ED" seeking assistance and must contain at a minimum, the name of the individual, the presenting complaint, the level of acuity or triage documented, and whether the individual:
7.2.1 Refused to be treated,
7.2.2 Was Refused treatment,
7.2.3 Was unable to be stabilized and transferred,
7.2.4 Was admitted and treated,
7.2.5 Was stabilized and transferred, or
7.2.6 Was discharged...".

Based on record reviews, interviews, review of the hospital's policy and procedure, medical/surgical unit census, diversion log, communication center audio recording, and review of the hospital's security video surveillance, the hospital's Emergency Department failed to ensure that an appropriate medical screening examination was conducted for 1 of 1 patients who presented requesting care. (Patient #24)

The findings are:

Review of Hospital A's video footage on 11/17/22 at 1:50 PM revealed Patient #24 arrived at Hospital A at 23:48:42 via stretcher vomiting blood upon entrance with Emergency Medical Services (EMS) Transport Crew #1. Video observations revealed Patient #24 arrived at the nurse station via EMS Transport #1 with paperwork in hand. At 23:49:18, three staff members are seen at the nurse station with two patients on stretchers in front of the station. At 23:49:25, one of the staff members from behind the desk went to the end of the nurse station by EMS transport # 1 and has a conversation with EMS staff. The Registered Nurse left exits down the hallway and returned at 23:50:06 with Registered Nurse (RN) #1. RN #1 has a conversation with EMS Transport #1 crew and at 23:50:30, RN #1 turned around, walked away, and sat down behind the nurse station. At 23:50:35, an unidentified physician walked past the patient and EMS Transport Crew #1 and entered an office. At 23:50:43, one of the EMS Transport Crew #1 medic made a hand gesture as if they were leaving and exited from the nurse station at Hospital A with Patient #24 via stretcher at 23:50:56 which was 2:14 (two minutes and fourteen seconds) post entrance.

Review of the Dedicated Emergency Department (DED) central log on 11/14/22 at 1:10 PM revealed the central log entries for 10/31/2022 showed no documentation for Patient #24 who presented to the ED via ambulance transport seeking treatment for gastrointestinal bleeding on 10/31/2022 at approximately 11:30 PM. The ED failed to create a patient chart or have documentation of a transfer or discharge.

During an interview on 11/16/22 at 7:19 PM, Registered Nurse (RN) #1 verified that he/she was on duty on 10/31/2022 at 11:30 PM when a patient arrived via ambulance transport with hematemsis. RN #1 stated, "During a flu surge, we had people in the hallways, and we were holding a lot of patients and other hospitals were without beds. The pager went off from the call center, and the patient that was coming was vomiting blood. We had a lot of patients we were already holding for GI (Gastrointestinal) beds greater than twenty-four hours waiting for transfer. I went to the ED (Emergency Department) doctor and told him/her the patient information given. The ER (Emergency Room) physician was okay with us sending the patient to another hospital. I and the physician tried to contact EMS (Emergency Medical Services) Transport Crew #1 prior to their arrival. I contacted the AOD (Administrator On Duty) as well. While I was waiting, the person at dispatch answered finally and said they would contact the truck. A room in the ED was prepared prior to the patient's arrival though. The physician waited but they (EMS) took too long and he/she had to leave from by the telephone waiting with me. They (EMS Transport #1) arrived and entered the double doors. I met them at the nurse station. I gave them (EMS) Room 6 for EMS to put the patient in. The EMS Transport #1 crew did not give me the transfer sheet or anything. She/He (EMS Transport #1 staff) went back to the patient and his crew person. They conversated and decided they would go to Hospital B's ED (Receiving hospital). The patient stated that his/her family would be looking for him/her here, and EMS said they would call the family to see if it would be okay. The doctor here never saw the patient. We don't know his/her name, age, nothing. The only info (information) we have is what was paged over to us. I had no conversation at all with the EMS crew on the side about the patient. I told them I called their dispatch to try to get them (dispatch) to divert, but since they were here, they(EMS) could go to Room #6. Then he (EMS Transport #1) went back and conversated with his partner and the patient. Less than three minutes was the entire event. I informed the AOD after they left. She(AOD) knew that I was contacting their dispatch and was okay with it. We were also on "Out of County" diversion and only EMS Transport #2 is to come to the ED. Even if it was EMS Transport #2, I would have still tried to get them(EMS) to divert. I felt it was in the best interest for the patient. About thirty minutes later, I saw the AOD in passing and she/he(AOD) told me to write it up. I called my manager and she/he(Manager) asked what happened. She/he(Manager) said she/he would talk with her boss and they would take it from there. They told me they would self-report the incident, and they were going to give us more EMTALA training. They sent out a flyer in an email and you scanned the flyer so they would know who did it and who didn't. It was an interactive training".

During an interview on 11/17/22 at 11:22 AM, the Director of Patient Flow and Operations for Midlands stated, "The Communication Center is two team members who listen to in-bound communication with the ambulance coming in. Once they have the info (information), they document that info and send the info to the charge nurse. This information is sent electronic via pager. Recently, we've been sending information over Telmediq for the past year. Some processes are via a page or via Telmediq. We track diversion information for all the hospitals. We do document when a diversion is for the hospitals and what EMS units are called".

During an interview on 11/17/22 at 12:42 PM, Administrator on Duty (AOD) #1 stated, "The ER was incredibly busy, several patients holding for admission, eighteen patients in lobby with a long wait, and the ER charge nurse asked if we could go on Diversion. So I called the communication center and we went on "Out of County" diversion only taking EMS transport #2. So I did that and she/he stated EMS Transport #1 patient for GI bleed was coming and I would put us on diversion and make the phone call. I went to do some other things and went up on the floor and this was around 11:30 PM. So around 4:30 AM or 5:30 AM, the ER charge nurse called me and said I want to give you a follow up on the patient. She/he said the patient came in and they told them we were on diversion and don't have GI services and they said we'll take him/her to Hospital B and turned around and left. She/he told them they could go to Room #6 so they had a room assignment. We had a discussion that that probably was not the best thing to do. I don't know if anyone else was involved in that discussion (for diversion). Typically, the ER physician will request it and then the charge nurse will reach out to me. Usually, there is some type of conversation that occurs. Typically, the communication center will call and make the call for us to the EMS dispatch. There was emails sent out by the ED nurse manager that was required to be completed about EMTALA training that we read through as a refresher. I cannot remember which physicians worked that night".

Review of Hospital A's Medical/Surgical unit on 11/15/22 at 11:34 AM revealed on 10/31/22, a midnight census of 40 of 40 beds in use.

Review of Hospital A "EMS Diversion Log" on 11/17/22 at 2:31 PM revealed Hospital A was on "Out of County" diversion on 10/31/22 at 23:33 by AOD #1 until 11/1/22 at 1:33 AM when it expired. EMS Transport #1 was contacted at 23:36 per log.

Review of Hospital A's "Communication Center" audio on 10/31/22 at 11:23:21 PM revealed "EMS Transport #1 in-bound, X year old female/male, chief complaint: vomiting blood, vital signs are as follows: BP (blood pressure) 147/84, Pulse (P) 125, Respirations (R) 18, SpO2 (Oxygen) 95% (percent) room air (RA), negative for Covid, ETA (estimated time of arrival) approximately twenty minutes".

The surveyor was unable to interview ED Physician (MD) #1 due to maternity leave for 2 weeks which started on 11/17/22.

Hospital policy, entitled, "Emergency Medical Treatment and Labor Act-EMTALA", revealed, "1. Obligations of Facilities with Dedicated Emergency Department and/or Obstetrical Services
1.1 Each individual Hospital A that has a dedicated ED ("DED") and/or provides Obstetrical (OB) Services has an obligation to provide a Medical Screening Examination ("MSE") by Qualified Medical Personnel to determine whether an emergency medical condition ("EMC") exists when an individual who is not already a patient comes to a Hospital A Dedicated Emergency Department ("DED") or to OB Department or otherwise presents on Hospital Property,...1.2 If an EMC is determined to exist, the individual should be provided necessary stabilizing treatment, within the capacity and capability of the Hospital A where the individual presents, or an appropriate transfer in compliance with EMTALA, regardless of the individual's ability to pay...".