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Based on review of hospital policies, medical flight service documents, audio and video recording, hospital documents and medical records and interview, the hospital failed to provide a medical screening examination (MSE) for 1 of 30 (Patient #16) patients who presented to the emergency department requesting treatment.

The findings included:

1. Review of the hospital's "EVALUATION AND TRANSFER OF PATIENTS WITH EMERGENCY MEDICAL CONDITIONS" policy revealed, "...Medical Screening...[name of Hospital #1] complies with federal statutes and regulations regarding the screening and transfer of patients with emergency medical conditions...Persons requesting examination or treatment for medical conditions are provided an appropriate medical screening examination to determine whether or not they have emergency medical conditions..."

Review of the hospital's "Medical Screening Examination" policy revealed, "...When an individual presents to the emergency department requesting examination or treatment of a medical condition, the medical screening examination is based on the individual's presenting complaint and is typically provided by a physician or a Nurse Practitioner or Certified Physician Assistant under the direct supervision of the emergency department physician..."

2. Review of 30 medical records revealed 1 (Patient #16) patient of the the sample who presented to the emergency department requesting treatment did not receive a medical screening examination.

Refer to findings in deficiency A2406.

Based on review of hospital policies, medical flight service documents, audio and video recording, hospital documents and medical records and interview, the hospital failed to provide a medical screening examination (MSE) for 1 of 30 (Patient #16) patients who presented to the emergency department requesting treatment.

The findings included:

1. Review of the hospital's "EVALUATION AND TRANSFER OF PATIENTS WITH EMERGENCY MEDICAL CONDITIONS" policy revealed, "...Medical Screening...[name of Hospital #1] complies with federal statutes and regulations regarding the screening and transfer of patients with emergency medical conditions...Persons requesting examination or treatment for medical conditions are provided an appropriate medical screening examination to determine whether or not they have emergency medical conditions..."

Review of the hospital's "Medical Screening Examination" policy revealed, "...When an individual presents to the emergency department requesting examination or treatment of a medical condition, the medical screening examination is based on the individual's presenting complaint and is typically provided by a physician or a Nurse Practitioner or Certified Physician Assistant under the direct supervision of the emergency department physician..."

Review of the hospital's "PATIENT ASSESSMENT" policy revealed, "...Patients entering the Emergency Department [ED]will be triaged and priorities of care assessed in relation to their physical and psychosocial needs...An initial assessment is required on all patients..."

Review of the hospital's "DIVERSION POLICY" revealed, "...The goal of the Emergency Department is to provide appropriate and expeditious treatment to all that seek medical care...Patients are diverted only when the hospital does not have the services required by the patient...PROCEDURE...The ED physician documents any patient that is not accepted and the reason or service that was not available..."

2. Review of the Flight Transportation Record #49855 dated 6/14/16 revealed Medical Flight Service #1's Aircraft #6 received a call at 5:37 PM to respond to a motor vehicle accident on Interstate 40 in Haywood County. Aircraft #6 with Flight Crew members #1, 2 and 3 arrived at the scene to transport the patient (Patient #16) to Hospital #1 per the patient's request. The patient was assessed by the Flight Crew as a 15 on the Glascow scale (a scale that rates potential brain injury, 15 being mild). The patient's vital signs were a blood pressure of 138/78. heart rate of 103, respirations 16 and oxygen saturation of 97%. The patient was listed as conscious, alert and oriented. The Flight Crew documented the receiving physician was Physician #1 at Hospital #1. Aircraft #6 landed at Hospital #1 at 6:10 PM. There were no hospital personnel or security staff present on the heli-pad at the time Aircraft #6 landed at Hospital #1. Flight Crew #1 entered Hospital #1, retrieved a stretcher, took it to the Aircraft, and along with the other Flight Crew transferred patient #16 onto the stretcher and took Patient #16 into Hospital #1's emergency department. Once in Hospital #1's ED, the Flight Crew were informed by Hospital #1 to take the patient to Hospital #2. The Flight Crew took Patient #16 back to the Aircraft. The patient did not receive a MSE at Hospital #1 prior to being re-loaded back into Aircraft #6 and being transferred to Hospital #2.

Review of the Flight Transportation Record #49856 dated 6/14/16 at 6:15 PM, revealed Medical Flight Service #1's Aircraft #6 left Hospital #1 and transported Patient #16 to Hospital #2. The record documented, "...PT. [patient] REQ. [requested] [name of Hospital #1]. LANDED AT PAD. UNABLE TO OFFLOAD..."

3. Review of an audio recording and a video recording dated 6/14/16 revealed the following (it was noted the times in the documentation, the audio recording and the video recording were not synchronized):

The audio recording revealed a radio conversation which involved Flight Crew #2, Nurse #3 from Hospital #1, Physician #1 from Hospital #1 and Dispatch #1 from Medical Flight Service #1.
At 5:21:32 PM Flight Crew #2 radioed Dispatch #1 to give report while in route from a motor vehicle accident to Hospital #1 with Patient #16.
At 5:23:00 PM Flight Crew #2 gave report to Nurse #3. Nurse #3 questioned why patient was not being transported to the trauma center at Hospital #2.
At 5:24:39 PM Flight Crew #2 confirmed Patient #16 refused to go to Hospital #2 and requested to come to Hospital #1.
At 5:25:36 PM Flight Crew #2 gave report to Physician #1 who then stated the patient needed to go to the trauma center.
At 5:26:39 PM Flight Crew #2 stated unless Hospital #1 was on diversion, they had to take him wherever he wanted to go, Patient #16 refused to go to Hospital #2, and he requested to go to Hospital #1.
At 5:26:59 PM Dispatch #1 asked Physician #1 if he had any other questions. There was an indistinct response from Physician #1, and Dispatch #1 stated, " ...ok, thank you. " At 5:27:07 PM Dispatch #1 notified Flight Crew #2 that Physician #1 copied.
At 5:38:22 PM Flight Crew #2 notified Dispatch #1 they were landing at Hospital #1.
At 5:57:02 PM Flight Crew #2 radioed Dispatch #1 they were leaving Hospital #1 with Patient #16 and transporting him to Hospital #2.

The video recording from Hospital #1 viewed the parking lot outside the emergency department (ED) toward the heli-pad. The video recording revealed on 6/14/16 at approximately 6:03 PM Flight Crew #1 walked from Hospital #1's heli-pad into the hospital entrance, returned to the heli-pad with a stretcher, and transferred Patient #16 onto the stretcher.
At 6:07:36 PM Flight Crew #1 and 2 were observed transporting Patient #16 from the heli-pad into the hospital and out of camera view.
At 6:08 PM Nurse #2 from Hospital #1 entered the camera view in the parking lot outside the ED and walked to the entrance where the Flight crew and taken Patient #16 out of camera view.
At 6:10 PM the Flight crew were observed taking Patient #16 out of Hospital #1 and transferring him back onto the the Aircraft.
At 6:11 PM Nurse #4 from Hospital #1 was observed outside of the hospital in the parking lot, and at 6:12 PM Nurse #2 walked outside the hospital into the parking lot. The 2 nurses were observed walking to the Aircraft and talking with 2 Flight crew members, then walking back into the hospital.
At 6:15 PM the Aircraft became airborne and departed Hospital #1 with Patient #16 on board.

There was no documentation Physician #1 had been notified that Patient #16 had arrived at the ED at Hospital #1. There was no documentation the patient had received a medical screening examination (MSE) at Hospital #1 prior to be transferred to Hospital #2. There was no documentation Hospital #1 called Hospital #2 and notified them that Patient #16 was being sent to their ED.

Review of the Hospital #1's document titled "RADIO LOG SECURITY DEPARTMENT" from dated 6/14/16 revealed Radio Dispatch #1 from Hospital #1 documented the hospital received a radio call from Medical Flight Service #1's Aircraft #6 at 5:42 PM with a 15 minutes estimated time of arrival. The flight was then documented as canceled on the same line of the log. At 6:09 PM Radio Dispatch #2 from Hospital #1 documented Medical Flight Service #1's Aircraft #6 was at the hospital but left at 6:15 PM. There was no documentation at Hospital #1 that Physician #1 had canceled Patient #16's arrival to the hospital's ED.

4. Medical record review for Patient #16 revealed the patient arrived at Hospital #2 on 6/14/16 at 6:37 PM via Aircraft #6. Patient #16 received a MSE and diagnosed with Right Lamina Papyracea Fracture, Right Elbow Laceration, Right Forearm Laceration and Right Wrist Laceration. The patient was discharged home in stable condition on 6/15/16 at 4:10 AM.

5. During an interview in the ED of Hospital #1 on 6/27/16, Nurse #1 from Hospital #1 stated any medical flight would call the hospital through the Medical Communication (Med Com) system to give report to the nurse or the physician and an estimated time of arrival.

During an interview in the conference room of Hospital #1 on 6/28/16 at 9:00 AM, Physician #1 from Hospital #1 confirmed he received a report from Medical Flight Service #1's Aircraft #6 on 6/14/16 concerning Patient #16. Physician #1 stated he advised the flight crew member on the radio that Patient #16 should go to the trauma center at Hospital #2. Physician #1 stated the flight crew member informed him that Patient #16 refused to go to Hospital #2 and requested to come to Hospital #1. Physician #1 stated he left the decision on where to go to the flight crew and the patient. Physician #1 stated he was unaware Medical Flight Service #1's Aircraft #6 had landed at Hospital #1 with Patient #16 until sometime the next day.

During an interview in the conference room of Hospital #1 on 6/28/16 at 10:05 AM, Nurse #2 from Hospital #1 stated she was in charge in the ED on 6/14/16, but Nurse #3 from Hospital #1 took report from Medical Flight Service #1's Aircraft #6 concerning Patient #16. Nurse #2 stated Nurse #3 then called Physician #1 to the radio to talk with the flight crew. Nurse #2 stated she had heard Physician #1 tell the flight crew over the radio to take Patient #16 to another hospital. Nurse #2 stated she thought the flight to the hospital was canceled and notified security. There was no documentation Physician #1 had told the nurse to cancel Patient #16's arrival to the ED.
Nurse #2 stated that when Medical Flight Service #1's Aircraft #6 landed on the hospital's heli-pad with Patient #16, security notified her. Nurse #2 stated when she went outside and noticed the flight crew had already unloaded Patient #16 from the helicopter and was bringing him into the hospital. Nurse #2 stated she met the flight crew to clarify the identity of the patient they were transporting. When the flight crew responded they were bringing in Patient #16, Nurse #2 stated she told the Flight crew that she had heard Physician #1 tell them to take Patient #16 to a higher level of care. Nurse #2 stated she talked with the flight crew for a few minutes until Patient #16 finally told the flight crew to take him wherever he needed to go. Nurse #2 stated the flight crew took Patient #16 back to the heli-pad, loaded him onto the Aircraft and departed Hospital #1.

During a telephone interview on 6/28/16 at 10:28 PM, the Medical Flight Service #1's Chief Flight Nurse stated the flight crew could only recommend to a patient which facility he or she should go based on possible injuries. The Chief Flight Nurse stated the flight crew would make all efforts to take a patient to the facility which provided an appropriate level of care, but the flight crew could not force the patient to go to a facility if the patient refused to go and was alert and oriented.

During a phone interview on 6/28/16 at 11:00 AM, Flight Crew #1 stated when they arrived at the scene of the accident on 6/14/16, Patient #16 was in an ambulance. Flight Crew #1 stated they received report from the ambulance personnel and spoke with Patient #16. Flight Crew #1 stated Patient #16 asked where he was being sent to, refused to go to Hospital #2 and stated he wanted to go to Hospital #1. Flight Crew #1 stated they informed Patient #16 that if he went to Hospital #1, they might transfer him to Hospital #2 or to another facility. Flight Crew #1 stated Patient #16 understood but still wanted to go to Hospital #1. Flight Crew #1 stated Patient #16 was intact neurologically and his injuries were not severe enough to require a level 1 trauma facility (such as Hospital #2). Flight Crew #1 stated when they arrived at Hospital #1, there were no staff or security officers waiting for them at the hospitals heli-pad. Flight Crew #1 stated she entered Hospital #1, obtained a stretcher and returned to the helicopter. Flight Crew #1 stated the flight crew loaded Patient #16 onto the stretcher and transported him into Hospital #1. Flight Crew #1 stated they were met by Nurse #2 who told them to take the patient to Hospital #2. Flight Crew #1 stated when she asked if the hospital was on diversion Nurse #2 stated, "No." Flight Crew #1 stated when she asked if they were going to treat Patient #16, Nurse #2 stated, "No." Flight Crew #1 stated Patient #16 then agreed to go to Hospital #2. The flight crew loaded him back on the Aircraft and transported him to Hospital #2.

During a phone interview on 6/28/16 at 12:24 PM, Flight Crew #2 stated when they arrived on the scene on 6/14/16, Patient #16 stated he was not going to Hospital #2 but wanted to go to Hospital #1. Flight Crew #2 stated he called report to Physician #1 at Hospital #1 who then advised them to go to Hospital #2. Flight Crew #2 stated he told Physician #1 the patient was refusing to go to Hospital #2 but the physician told them he needed to go anyhow. Flight Crew #2 stated he told Physician #1 that unless the hospital was on diversion, the Flight Crew had to bring Patient #16 where he wanted to go and could not force him to go to Hospital #2 if he refused. Flight Crew #2 stated when they arrived at Hospital #1 no one from Hospital #1 was there to meet them on the heli-pad and Flight Crew #1 went into the hospital, retrieved a stretcher, and they transported Patient #16 into the hospital. Flight Crew #2 stated they met Nurse #2 f who informed them the hospital could not take Patient #16. Flight Crew #2 stated after a brief conversation, Patient #16 finally agreed to be taken to Hospital #2. Flight Crew #2 stated they loaded Patient #16 back on the Aircraft and transported him to Hospital #2.

During an interview in the conference room of Hospital #1 on 6/28/16, the Nurse Manager of the ED from Hospital #1 stated Hospital #1 does not go on diversion. The Nurse Manager of the ED stated an ED physician can make a recommendation for a patient being transported by emergency medical services (EMS) services to be transported to another facility with a higher level of care but cannot refuse to accept a patient who chose to come to Hospital #1. The Nurse Manager of the ED stated anyone who shows up on the hospital campus seeking medical treatment is considered a patient and must be treated in the ED. If a patient cannot be adequately treated in the ED, the ED staff must stabilize the patient and then arrange for transport to a facility with the appropriate level of care.

During a phone interview on 6/28/16 at 1:50 PM, Flight Crew #3 stated Patient #16 requested to go to Hospital #1 when they picked him up after his accident. Flight Crew #3 stated when they arrived at Hospital #1, there was no staff from the hospital to assist with the patient. Flight Crew #3 stated they took the patient inside Hospital #1 on a stretcher, but Nurse #2 from Hospital #1 told them the hospital would not accept the patient. Flight Crew #3 stated the patient finally agreed to be transported and treated at Hospital #2. Flight Crew #3 stated they loaded the patient back on the Aircraft and transported him to Hospital #2.

During an interview in the conference room of Hospital #1 on 6/29/16 at 9:18 AM, the Director of Risk Management, Infection Prevention and Patient Relations at Hospital #1 stated Hospital #1 was never on diversion. The Director stated anyone on the hospital campus who sought medical treatment was patient of the hospital.

During a phone interview on 6/29/16 at 11:30 AM, the ED Medical Director from Hospital #1 stated he spoke with Physician #1 from Hospital #1 on 6/15/16 about the incident involving Patient #16 which occurred on 6/14/16. The ED Medical Director stated Physician #1 felt like Patient #16 needed to go to Hospital #2 but did not refuse for him to come to Hospital #1. The ED Medical Director stated Physician #1 told him that he expected Patient #16 to arrive at Hospital #1 but did not know until the next day (6/15/16) that Medical Flight Service #1 landed on the hospital property with Patient #16. The ED Medical Director stated Physician #1 told him that he was not informed of Patient #16's arrival by any of the ED staff.

During a phone interview on 6/29/16 at 7:08 PM, Patient #16 stated he requested to go to Hospital #1 after his accident. Patient #16 stated when the Aircraft landed at Hospital #1, the flight crew loaded him onto a stretcher and took him inside the hospital. Patient #16 stated they met the charge nurse (Nurse #2 from Hospital #1) who stated they would not accept him as a patient. Patient #16 stated the flight crew had a discussion with the charge nurse until he finally told them to just take him where he could be treated. Patient #16 stated the flight crew loaded him back on the Aircraft and took him to Hospital #2.